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PERKINS  LIBRARY 

Duke   University 

l\are  Doolcs 

\A^t3-vS-$>JV 

L  '    ' 

DISSERTATIONS 


ON 


INFLAMMATION. 


VOLUME  I. 


CONTAINING, 


PRELIMINARY  DISSERTATION-ON  SOME  OP  THE  LAWS  OF  THE 
ANIMAL  ECONOMY.  DISSERT.  II-ON  THE  HISTORY,  CAUSES, 
AND  CONSEQUENCES  OF  SIMPLE  INFLAMMATION. 


BY    JOHN    BURNS, 

SURGEON  IN  GLASGOW. 

'o' 

PUBLISHED  BY  E.  F.  BACKUS, 

AT  THH   ALBANY  BOOKSTORE,  NO.   45   STATE  STRSBX. 

C  S.  Van  Winkle,  Printer,  Neni-York. 
1812; 


ALBANY: 


CONTENTS. 


VOL.  I. 

Preliminary  Dissert. — On  some  of  the  Laws  of 

the  Animal  Economy,     .        .         .        .        .         13 

Dissert.  II. — On  the  History,  Causes,  and  Termi- 
nations of  Simple  Inflammation,     .         .         .131 

VOL.  II. 

Dissert.  II.  continued. — On  the  Treatment  of  Sim- 
ple Inflammation,  and  its  Consequences,           .  3 
Dissert.  III. — On  the  Phagadenic,  and  some  other 

Species  of  Inflammation,         .         .         .         .118 

Dissert.  IV. — On  the  Spongoid  Inflammation,      .  132 

Dissert.    V. — On  the  Scrophulous  Inflammation,  145 

Dissert.  VI. — On  the  Cancerous  Inflammation,     .  177 


r 

PREFACE. 


THE  foundation  on  which  medical  reasonings 
are  built,  is  a  knowledge  of  the  laws  and  opera- 
tions of  the  living  principle  ;  but  as  our  acquaint- 
ance  with  these  is  exceedingly  imperfect,  the  opi- 
nions which  are  formed  from  this  must  be  fluctuat- 
ing, and  frequently  very  uncertain. 

When  physic  first  became  a  science,  the  doc- 
trines of  its  teachers  were,  of  necessity,  rude  and 
chimerical ;  and  even  after  it  had  been  studied  for 
many  hundred  years,  it  continued  to  be  obscured 
by  a  multitude  of  idle  theories.  As  these  were 
founded  not  on  facts,  but  on  what  the  imagination 
of  their  inventors  believed  to  be  probable,  it  is  not 
wonderful,  that  each  succeeding  teacher  should 
change  and  modify  the  doctrines  of  his  predeces- 
sor :  But  even  these  changes,  however  highly  they 
might  be  valued  by  the  school  which  effected  them, 
embraced  only  a  very  small  extent.  The  more 
trifling  parts  of  the  system  alone  suffered  an  alter- 
ation; and  the  great  outlines  of  former  opinion 
seemed  to  be  beheld,  for  ages,  as  boundaries  mark- 
ed out  by  a  Superior  Being  to  the  human  under - 

Vol.  I.  B 


landing,  and  marked  with  the  character?,  Hitherto 
shalt  thou  come,  but  no  farther.    For  by  far  the 
longest  period  of  medical  history,  we  find  these  out- 
lines to  be  drawn  on  a  wrong  foundation ;  the  prin- 
ciples of  pathology  being  taken  from  the  proper- 
ties and  conditions  of  the  different  fluids  of  the 
body.     In  the  first  ages  of  knowledge,  the  mind 
was  impressed  with  material  objects  alone,   and 
was  able  to  reason  only  concerning  objects  of  sense. 
That  the  grosser  part  of  matter  must  have  some 
more  subtle  power  acting  on  it,  m  order  to  make 
it  perform  its  operations,  appeared  evident  to  all ; 
but  of  this  they  could  form  no  idea,   otherwise 
than  by  supposing  an  intelligence  which,  by  its 
active  qualities,  could  operate  just  as  man  moves 
and  regulates  the  machines  which  he  makes.   The 
nature  of  this  intelligence  they  also  endeavoured 
to  explain  ;  but,  by  having  their  minds  tied  down 
wholly  to  material  objects,  the  ancient  philosophers 
could  form  no  conception  of  a  principle  purely 
spiritual.    They,  therefore,  chose  the  most  subtle 
matter  with  which  they  were  acquainted  ;  and  be- 
lieved heat,  or  a  principle  to  which  they  gave  this 
appellation,  to  be  the  soul  of  the  universe,  from 
which  emanations  went  forth  to  enliven  the  indi- 
viduals of  the  creation.     Such  being  the  doctrines 
of  the  philosophers,  medical  reasonings  came  natu- 
rally to  be  founded  on  the  properties  and  changes 
of  the  material  part  of  the  frame,  which  changes 
were  again  referred  to  the  operation  of  an  intelli- 
gent and  sentient  principle. 


Xi 

It  was  the  discoveries  of  the  immortal  Newton, 
which  first  paved  the  way  for  the  real  improve- 
ment of  medical  science  ;  for  he,  in  one  great 
branch  of  natural  knowledge,  banished  completely 
the  mechanical  interference  of  intelligent  agents, 
and  taught  the  existence  of  a  principle  purely  im- 
material, and  which,  without  any  wisdom  or  voli- 
tion, could  act  by  being  acted  on.  The  mind  now 
Came  gradually  to  be  weaned  from  reasonings  to- 
tally material  and  mechanical ;  and  physicians,  by 
degrees,  began  to  attribute  the  operations  of  the 
animal  frame,  not  to  a  thinking  power,  which  pre- 
sided with  wisdom  over  the  system,  but  to  a  prin- 
ciple, which  was  implanted  in  man  at  his  creation, 
and  which,  through  the  medium  of  the  nerves,  in 
which  it  was  supposed  to  be  lodged,  carried  on  his 
functions,,  according  to  a  rule  established  from  the 
beginning,  without  possessing  either  knowledge  or 
judgment.  It  required,  however,  a  step  farther 
to  banish  the  doctrines  of  the  changes  of  the  fluids, 
and  the  belief  in  these  as  the  cause  of  disease ;  and 
so  strongly  have  these  notions  taken  hold  of  the 
mind,  that  they  are  not  yet  altogether  given  up. 

An  examination  into  the  properties  and  source 
of  this  living  principle,  or  nervous  energy,  as  it 
has  been  called,  forms  the  subject  of  the  Prelimi- 
nary Dissertation,  in  which  I  have  endeavoured  to 
explain  some  of  the  principal  laws  and  operations 
of  the  animal  economy.  The  subsequent  Disser- 
tations contain  an  inquiry  into  the  nature  and  mode 
of  treatment  of  some  of  the  different  species  of  in- 


Xli 

flammation,  founded  upon  those  laws  or  properties 
of  the  living  principle.  These  are  part  of  a  course 
of  lectures  which  I  read  upon  surgery,  three  years 
ago,  in  the  Royal  Infirmary,  in  Glasgow. 

I  offer  them  now  to  the  Public  with  much  diffi- 
dence ;  but,  at  the  same  time,  with  a  sincere  hope 
that  they  may  be  useful  to  others,  in  considering 
the  same  subjects,  which  are  of  the  very  first  im- 
portance to  every  surgeon.  If,  in  any  part,  I  shall 
appear  to  be  unnecessarily  tedious,  I  beg  it  to  be 
remembered,  that  some  of  these  positions  differ 
from  those  commonly  maintained,  and,  therefore, 
require  to  be  more  fully  illustrated.  I  do  not 
write  to  surgeons  who  already  understand  these 
subjects,  but  to  students,  who  as  yet  have  their 
knowledge  to  acquire,  and  to  whom  many  illus- 
trations are  useful,  which  to  others,  who  know 
more,  may  appear  to  be  unnecessary. 


DISSERTATIONS 


ox 


INFLAMMATION- 


PRELIMINARY    DISSERTATION     ON    SOME    OF    THE    LAWS    OF 
THE    ANIMAL    ECONOMY. 


Introduction. 

NATURAL  historians  have  divided  the  objects  of  their 
examinations  into  three  great  classes,  which  have  been  called 
the  kingdoms  of  oature ;  the  animal,  the  vegetable,  and  the 
mineral. 

Amongst  all  the  different  individuals  of  these  divisions,  an 
organised  form  regularly  prevails.  A  stone  or  a  salt  assumes 
uniformly  an  appearance  which  continues  always  the  same  in 
similar  species.  The  vast  rocks  of  Basaltes,  which  stand  as 
so  many  monuments  of  the  dreadful  cause  which  produced 
them,  consist  of  large  pillars,  having  five  sides  of  equal  di- 
mensions. Silicious  crystals  exhibit  the  form  of  hexagonal 
pyramids,  whilst  the  zeolite  assumes  the  figure  of  a  beautiful 
star,  and  the  amianthus  that  of  regular  and  parallel  fibres. 

The  vegetable  has  likewise  its  appropriate  construction, 
which,  as  in  the  other  kingdoms,  continues  always  the  same  ; 
but  in  this  respect  it  differs  from  the  mineral,  that  to  a  regu- 
lar figure  there  are  conjoined  organic  vessels  to  maintain  and 


14 

increase  that  form,  according  to  the  uniform  action  of  a  cer- 
tain principle  which  they  possess,  and  which  has  been  called 
life.  If  the  plant  be  cut  through  level  with  the  earth,  we 
soon  find  that  the  loss  is  supplied,  and  new  sprouts  formed, 
which  produce  leaves,  flowers,  and  fruit,  exactly  similar  to 
those  which  were  cut  down.  If  we  apply  a  stimulus  to  it,  a 
particular  effect  is  produced,  according  to  the  nature  of  the 
application,  or  of  the  part  acted  on.  If  it  be  light,  the  organs 
of  motion  become  affected,  and  the  leaves  turn  toward  the 
ray,  or  the  flower-leaves  open  to  admit  the  light  and  air  to  the 
parts  of  fructification.  If  heat  be  applied  to  the  plant,  in  a 
slow  and  regular  manner,  it  supports  and  assists  the  exercise 
of  its  functions,  and  consequently  contributes  to  its  strength 
and  increase.  But  if  it  be  applied  hastily,  and  to  a  great  de- 
gree, it  disorders  the  action  of  that  power  which  preserves 
the  plant,  and  either  disease  or  death  is  the  result.  The  laws 
and  operations  of  this  power  are  few  and  simple ;  but  when 
we  ascend  to  the  animal  creation,  we  find,  that  not  only  the 
structure  is  more  complex,  but  also  the  modes  of  action  are 
much  more  numerous. 

The  individuals  of  the  last  class  have  promiscuously  re- 
ceived the  name  of  dead  matter,  because,  when  compared 
with  the  other  classes,  they  appeared  to  be  inanimate.  But 
by  a  more  accurate  examination,  we  shall  find,  that  there  is 
in  reality  no  individual  whatever  in  any  of  the  kingdoms  or 
classes  of  nature  which  can  be  called  inert,  or  truly  dead. 
For,  from  the  largest  masses  of  matter  down  to  the  most 
minute  corpuscles,  we  distinctly  perceive  the  operation  of  an 
active  and  immaterial  principle.* 

*  The  particular  nature  of  this  principle,  as  we  shall  afterwards  see,  never  can 
he  ascertained.  We  are,  however,  sufficiently  assured,  by  the  phenomena  whicli 
we  observe,  that  in  all  the  classes  of  nature  such  a  principle  does  exist.  But  the 
relation  which  the  enlivening  or  vital  powers  of  one  class  bears  to  that  of  another, 
cannot  yet,  if  ever,  be  determined.  Whether  the  same  principle  only  exists  in  dif- 
ferent degrees  of  perfection  in  these  classes,  or  whether  its  nature  be  essentially 
diflferent  in  each,  will  admit  of  much  discission.  In  this  paper,  however,  I  can 
anry  give  a  general  statement  of  the  i'Jea  which  I  annex  to  the  principle  of  life,  and 


15 

This  principle  has  received  different  names,  according  as  it 
manifests  itself.  The  power  which  supports  the  functions, 
(if  I  may  use  the  expression,)  and  regulates  the  motions  and 
actions  of  the  different  parts  of  the  universe,  has  been  called 
gravitation ;  whilst  the  property  whkh  makes  one  particle 
unite  with  another,  and  which  modifies  the  form,  and  produces 
the  increase  of  the  smaller  bodies,  has  received  the  name  of 
corpuscular  attraction.  The  principle,  again,  which  regu- 
lates the  intestine  changes,  and  determines  the  combinations 
and  specific  states  of  existence  in  matter,  has  been  denomi- 
nated elective,  or  chemical  attraction. 

How  matter,  which  by  itself,  and  viewed  abstractedly,  must 
be  considered  as  inert  and  dead,  should  Be  capable  of  com- 
bining with  this  active  and  immaterial  power,  it  is  impossible 
to  say.  But  having  from  the  creation  perceived  this  union, 
we  find  it  to  be  now  impracticable  to  form  a  conception  of 
matter  unconnected  with  this  property. 

Without  this  enlivening  principle,  all  nature  must  be  dead ; 
and  matter  deprived  of  it  must  either  cease  to  exist,  or  exist 
in  a  way  which  we  cannot  possibly  comprehend.  The  union 
of  the  whole  universe  must  be  dissolved,  and  the  beautiful  de- 
pendence of  one  part  on  the  rest  for  ever  destroyed.  We 
know,  and  are  taught  to  believe,  that  the  Great  Being  who 
formerly  sent  forth  this  active  vital  power,  and  bade  the 
worlds  live,  will  one  day  recal  his  gift.  Matter  shall  then 
cease  altogether  to  be,  or  shall  return  to  that  unknown  chaotic 
state  which  poets  have  imagined,  and  vainly  attempted  to 
describe.*     The  particular  laws  and  operations  of  attraction, 

afterwards  mention,  in  so  far  as  will  be  necessary  for  understanding  the  following 
Dissertations  on  Inflammation,  some  of  the  operations  and  qualities  of  the  Jh:Ti£ 
principle  in  man. 

*  "  Ante,  mare  et  tellus,  et,  quod  tegit  omnia,  ccelunjj 
"  Unus  erat  toto  nature  vultus  in  orbe, 
"  Quern  dixere  chaos ;  rudis  indigestaque  moles ; 
14  Nee  quicquam,  nisi  pondus  iners;  congestaque  eodf>m 
"  Nod  beae  junctarv(m  discordia  senjina  rennn." 

Ovp. 


16 

or  the  life  qf  mailer,  belong  for  investigation  to  the  natural 
philosopher;  and  therefore  it  will  here  only  be  proper  to  re- 
mark, that  I  consider  animals,  vegetables,  and  what  is  called 
inanimate  matter,  as  all  possessing  an  immaterial  principle, 
differing  greatly  indeed  in  its  nature  and  effects  in  these  dif- 
ferent classes,  but  still  deserving,  in  all  of  them,  the  name  of 
life,  being  of  equal  value  to  each,  and  absolutely  requisite  for 
their  preservation. 

This  power,  we  have  seen,  is  exceedingly  simple  in  com- 
mon matter ;  but  when  we  mount  to  the  next  class,  that  of 
vegetables,  we  find  a  much  greater  degree  of  perfection  in 
the  life,  and  much  more  complicated  actions.  We  have  not 
only  the  same  properties  which  are  possessed  by  matter,  but 
also  additional  and  very  surprising  powers.  We  find  them 
always  in  a  progressive  stale  of  growth  or  decay,  endowed 
with  the  property  of  changing  foreign  matter  into  a  peculiar 
fluid,  which  is  continually  circulated  through  their  vessels, 
and  converted  into  a  great  variety  of  products.  They  are 
farther  distinguished,  by  having  within  themselves  the  powers 
of  motion,  and  of  multiplying  their  species  to  an  endless  de- 
gree. We  then  find,  that  vegetables  possess  not  only  the 
principles  proper  to  matter,  but  also  a  life  peculiar  to  them- 
selves, and  which,  I  may  say,  is  built  upon  the  former  ;  for 
without  attraction  there  can  be  neither  growth  nor  organiza- 
tion. 

When  we  ascend  to  animals,  we  find  them  possessed  of  a 
third  species  of  life,  built  upon  the  other  two.  In  this  class, 
beside  attraction,  or  the  preserving  and  active  principle  of 
matter,  we  find  reproduction,  and  the  other  properties  of  ve- 
getable life  ;  but  these  properties  are  exhibited  with  a  differ- 
ent modification,  and  are  united  with  others,  which  of  them- 
selves would,  independent  of  the  presence  of  mind,  distin- 
guish them  from  vegetables. 


17 

We  have,  then,  in  the  three  classes  of  nature,  three  dif- 
ferent species  of  life,  each  more  perfect  than  the  other,  and 
increasing  gradually  in  their  delicacy  and  intricacy.  The 
most  simple,  or  that  of  matter,  is  the  most  permanent,  and 
on  it  the  other  two  are  built.  I  do  not,  however,  mean  from 
this  to  say,  that  attraction,*  or  the  vital  principle  of  matter, 
acts  in  the  higher  classes  merely  as  attraction ;  or,  in  other 
words,  that  it  remains  unchanged  in  its  properties.  On  the 
contrary,  a  very  great  alteration  takes  place ;  and,  although 
it  still  possesses  the  quality  expressed  by  the  word  attraction, 
making  the  parts  adhere  together,  it  yet  is  so  far  changed 
and  perfected,  as  to  exhibit  many  other  phenomena  and  new 
actions,  of  which,  before  this  elevation,  it  was  incapable.  It 
is  rendered  not  only  more  perfect,  in  this  respect,  of  gaining 
new  properties,  but  even  its  original  quality  of  producing  at- 
traction is  much  improved  ;  for  a  living  muscle  will  bear  a 
greater  weight,  without  laceration,  than  one  newly  dead,  or 
one  called,  in  common  language,  dead ;  which  proves,  that 
the  vital  principle,  in  animals,  has  a  greater  power  of  pro- 
ducing the  effect  called  attraction,  than  the  vital  principle  of 
common  matter. 

The  three  classes  run  imperceptibly  into  each  other  ;  and 
thus  we  have  a  complete  chain  of  existence  established,  from 
the  most  simple  to  the  most  complicated  body.  Those  spe- 
cies of  amianthus,  which  are  called  mountain  cork,  although 
minerals,  yet  resemble  vegetables  so  strongly,  that  they  link 
the  classes  together ;  whilst  the  coralines,  although  animals, 
resemble  both  minerals  and  vegetables.  The  fungi,  though 
plants,  consist  of  the  same  principles  with  animals.  Some 
of  the  fuci  resemble  hair,  and  other  cartilage  ;  whilst  the 
sponge,  although  an  animal,  grows  like  a  vegetable.  Not 
only  the  external  and  chemical  qualities,  but  also  the  vital 

*  This  term  is  used  sometimes  for  the  cause,  and  sometimes  for  the  effect  j  but 
<  he  sense  will  always  show  how  it  is  to  be  understood, 
VOIr.   I.  C 


T8 

principle,  and  its  phenomena,  form  a  regular  gradation  in  fhe 
different  classes.  Even  in  a  single  individual  of  the  two' 
higher  classes,  we  perceive  the  gradual  elevation  of  one  spe- 
cies of  life  into  another.  This  change  uniformly  begins  in 
the  fluid  part  of  the  individual.  In  the  plant,  the  first  change 
produced  on  common  matter,  or  the  aliment,  is  its  conver- 
sion into  vegetable  juices,  which  exhibit  certain  vital  pheno- 
mena, different  from  common  fluid  matter  :  afterwards  or- 
ganization is  added,  in  which  the  vegetable  life  is  exhibited 
with  most  perfection.  In  animals,  again,  there  is  a  greater 
gradation,  and  more  complicated  change,  before  animal  life 
be  imparted  in  its  greatest  perfection.  The  food  is  first  con- 
verted into  chyle,  which  has  a  lower  species  of  life  than  the 
blood,  which  again  is  more  imperfect  io  its  vitality  than  the 
organized  parts.  The  living  principle  of  the  blood  differs, 
both  in  degree  and  kind,  from  that  which  belongs  peculiarly 
to  the  animal ;  but  these  two  are  connected,  and  react  on 
each  other. 

No  substance  or  piece  of  matter,  whether  simple  or  com 
pound,  has  of  itself  a  tendency  to  decomposition,  or  change 
of  state.  For  effecting  this,  the  principle  of  attraction  must 
be  acted  on  by  the  addition  of  olher  substances,  and  then 
a  new  condition  will  take  place.  This  is  the  foundation  of 
chemistry,  which  is  a  science  wholly  built  on  the  effects  of 
attraction.  Some  have  attempted  to  explain  the  changes  or 
diseases  of  living  animals  by  the  same  law*  ;  but  this  method 
cannot  be  admitted,  until  it  be  proved,  that  their  life  does 
not  give  them  properties  different  from  common  matter,  and 
make  them  subject  to  another  set  of  laws.  When  they  are 
deprived  of  this  life,  then  they  become  liable  to  the  habi- 
tudes of  matter,  and  may,  by  the  agency  of  other  substances, 
be  decomposed,  and  differently  combined ;  but,  until  their 
specific  life  be  lost,  they  bid  defiance  to  such  changes  ;  and. 
therefore,  the  system  of  pathology  which  ha?  been  built  ur> 
on  it  must  be  fakes 


19 

Life  is  a  principle  which  we  can  only  detect  and  judge  of 
by  its  operations  or  actions  ;  and,  when  these  are  not  exhibit- 
ed, we  are  apt,  though  sometimes  erroneously,  to  conclude, 
that  the  body  is  dead.  The  leading  property  of  life,  is  to 
-communicate  a  preservative  power  to  every  individual  with 
which  it  is  connected.  This  is  sometimes  effected  by  very 
evident  and  intricate  actions  ;  but,  at  other  times,  is  exerted 
without  any  sensible  operation.  The  crystal  resists,  to  a 
certain  degree,  mechanical  impressions,  which  would  destroy 
its  form.  The  blood  when  newly  drawn,  the  sap  of  vegeta- 
bles, the  living  egg,  resist  cold,  by  an  imperceptible  opera- 
tion, to  a  much  greater  degree,  when  alive,  than  after  their 
peculiar  life  departs.  They  resist  all  the  efforts  of  chemical 
agents  which  act  on  common  matter  ;  nor  is  it  possible  to  de- 
compose or  injure  them  in  this  way,  until  they  lose  therr 
specific  life,  and  descend  in  the  scale  of  existence.  This 
simple  preservative  power  is  a  discriminating  mark  of  the 
presence  of  life  ;  but  we  cannot  detect  it  until  we  apply  de- 
stroying causes  :  It  is  the  uniform  and  universal  effect  of  the 
combination  of  life  with  any  substance,  whatever  its  nature  or 
structure  may  be :  It  is  the  essential  characteristic  of  life, 
which  it  must  show  whenever  it  is  present.  But,  when  we 
find  vital  power  united  with  a  certain  organization,*  then 
more  varied  phenomena  take  place  ;  and  these  are  called  ac- 
iions  of  the  vital  principle. f  In  the  plant,  the  bud  expands, 
the  stem  shoots  up,  the  food  is  absorbed,  digested,  and  cir- 
culated ;  air  is  thrown  out,  and  particular  secretions  take 
place.  In  the  animal,  these  actions  are  still  more  evident, 
but  more  intricate,  and  infinitely  more  varied.  They  are 
ihe  support  of  our  health,  and  the  source  of  all  our  disease. 

*  I  am  only  here  considering  animal  life,  without  any  connection  with  an  in- 
telligent principle  or  soul,  which  is  quite  a  different  thing  from  vitality. 

t  Every  operation  of  the  vital  energy  is  called  an  action,  and  whatever  agent 
excites  this  action  is  called  a  stimulus.  The  aptitude  of  the  system  to  be  acted 
•en  has  been  expressed  by  the  term  irritabijit- 


20 

In  the  two  first  classes,  the  enlivening  principle  seems  to 
be  equally  united  with  and  dependent  on  every  part  ;•  but  in 
animals,  to  whom  I  will  now  confine  my  attention,  the  prin- 
ciple which  performs  these  actions  is  more  directly  connect- 
ed with  certain  organized  portions  of  the  body,  called  brain 
and  nerves,  which  supply  every  part,  though  so  minutely, 
that  we  often  cannot  trace  their  course. 

Of  the  Brain  and  Nerves. 

The  brain*  is  a  soft  globular  substance  contained  within 
the  cranium,  of  a  dusky  colour  without,  but  white  in  the  cen- 
tre. It  is  from  this  white  or  medullary  portion,  that  we  find 
all  those  elongations  arising,  which  have  been  called  nerves, 
and  which  are  just  portions  of  the  brain  diffused  over  the 
body,  and  exerting  there  the  peculiar  properties  of  the  sys- 
tem to  which  they  belong. 

*  Were  we  to  proceed  regularly  to  investigate  the  various  phenomena  of  animal 
life,  we  would  naturally  begin  by  examining  the  composition  and  structure  of  the 
different  parts  of  the  body.  By  this  examination,  we  should  become  acquainted 
with  some  fundamental  facts,  but  should  still  be  in  the  dark  with  regard  to  that 
principle  which  animates  the  whole,  and  enables  the  various  functions  to  be  car- 
ried on.  An  inquiry  into  the  general  laws  of  this  energy,  which  is  found  to  re- 
side in  the  brain  and  nervous  system,  would,  therefore,  naturally  become  the 
second  object  of  our  attention.  Being  acquainted  with  these,  we  would  next  ex- 
amine the  particular  functions  of  man,  and  the  operation  of  the  nervous  energy  in 
supporting  them.  The  gradual  growth  and  increase  of  the  animal,  the  deposition 
of  new  matter,  and  the  absorption  of  the  old,  would  be  the  first  subject  of  conside- 
ration in  this  part  of  the  examination,  and  would  naturally  involve  an  inquiry 
into  the  process  of  digestion,  and  the  formation  of  the  blood,  with  its  qualities  and 
uses.  The  powers  of  motion,  the  influence  of  the  mind,  and  the  history  of  the  dif- 
ferent senses  and  various  functions  of  man,  would  conclude  this  part  of  the  inqui- 
ry. Having  become  acquainted  with  the  healthy  condition  of  the  system,  and 
the  causes  which  maintain  it,  we  would  apply  this  knowledge  to  the  investigation 
of  the  different  derangements,  or  diseased  actions  of  our  body,  and  their  cure. 

Such  might  be  a  proper  plan  for  examining  regularly  the  economy  and  diseases 
of  an  animal ;  but  this  would  be  greatly  too  extensive  for  the  present  purpose.  It 
must  here  be  taken  for  granted,  that  the  student  is  acquainted  with  the  structure 
of  the  body,  and  with  its  different  functions,  by  which  he  will  be  able  to  under- 
stand the  following  general  observations  on  the  properties  of  the  living  principle, 
and  apply  the  doctrines  more  par  ticularly  himself 


21 

These  nerves  possess  different  qualities,  according  to  the 
portion  of  the  brain  from  which  they  arise,  and  the  or- 
ganism of  the  part  to  which  they  go.  Those  which  go  out 
first,  arising  from  the  mamillary  processes,  and  which  are 
called  olfactory  nerves,  are  the  source  of  the  sense  of  smell- 
ing. The  second  pair,  arising  from  a  particular  protube- 
rance, or  little  brain,  called  the  optic  bed,  give  the  important 
sense  of  seeing  ;  and,  in  order  to  connect  those  two  cerviculae, 
or  beds,  we  find  their  elongations  joined,  before  they  proceed 
out  of  the  skull.  The  third,  the  fourth,  the  first  branch  of 
the  fifth,  and  the  sixth  pair  of  nerves,  all  arise  from  the  cere- 
brum, and  are  distributed  on  the  different  parts  of  the  eye, 
serving  chiefly  for  the  purposes  of  motion.  The  soft  portion 
of  the  seventh  pair  arises  from  the  fourth  ventricle,  and  con- 
stitutes the  auditory  nerve.  None  of  these  nerves  support 
the  vital  functions  ;  they  are  all  destined  either  for  the  organs 
of  sense,  or  the  simple  parts  about  the  head. 

The  nerves  which  serve  for  carrying  on  the  vital  functions, 
all  arise  either  from  the  medulla  oblongata,  or  spinal  marrow. 
I  have  seldom,  in  dissections,  found  derangements  of  those 
parts  of  the  brain,  but  have  often  observed  very  great 
disease  in  the  cerebrum.  In  one  case,  the  cerebrum  was 
hard  and  schirrus,  but  the  cerebellum  was  sound  and 
healthy.  This  man  died  comatose,  after  being  long  tor- 
mented with  violent  head-aches.  In  another  instance,  al- 
though the  lateral  ventricles  were  so  much^distended  with 
water,  that  the  hemispheres  of  the  brain  were  converted  into 
little  else  than  two  bladders  full  of  fluid,  yet  the  child  was 
sensible  nearly  to  the  time  of  death,  which  was  produced 
more  by  the  pressure  on  the  cerebellum,  which  was  not  dis- 
eased, than  by  the  derangement  of  the  cerebrum.  In  num- 
berless instances,  we  find  the  skull  beat  in  upon  the  cere- 
brum, or  foreign  bodies  lodged  in  its  substance,  or  abscesses 
Formed  in  consequence  of  blows  and  falls,  and  still  the  patient 


22 

surviving  all  the  injury.*  The  physiologist  has  even  re- 
moved this  part  of  the  brain  altogether,  in  birds  and  other 
animals,  without  death  being  occasioned ;  the  senses  alone 
were  destroyed.  But  it  is  equally  well  attested,  that  the 
cerebellum  cannot  be  injured  with  the  same  impunity  ;  for, 
from  the  history  of  those  who  are  killed  by  blows  on  the 
head,  and  by  experiments  upon  brutes,  we  find,  that,  in  very 
£ew  instances,  does  the  animal  survive,  if  this  part  of  the 
brain  be  injured. f 

We  shall  next  find,  that  the  cerebellum,  comprehending 
its  production,  the  medulla  oblongata,]:  joined  by  a  few 
branches  from  the  cerebrum,  is  expanded  or  diffused  over 
the  whole  body.  It  passes  out  of  the  skull,  and  seeks  de- 
fence in  the  vertebral  canal,  from  whence  it  sends  out  elon- 
gations to  all  the  different  parts  of  the  body,  which,  with 
those  which  pass  out  from  it  in  the  skull,  support  the  exist- 
ence of  the  animal. 


*  I  do  not  mean  to  maintain,  that  wounds  of  the  cerebrum  are  not  attended 
with  great  danger.  I  only  wish  to  prove,  that  they  are  by  no  means  so  fatal  as 
those  of  the  cerebellum  j  and,  consequently,  that  the  cerebrum  is  not  so  immedi- 
ately necessary  to  the  continuance  of  life.  Spindler,  and  others,  report  instances 
of  people  walking  about  with  part  of  the  cerebrum  gangrenous.  Many  instances 
of  recovery  from  severe  injuries  done  to  this  part,  are  mentioned  in  the  Memoirs 
of  the  Academy  of  Surgery ;  and  every  practical  surgeon  must  have  observed, 
how  long  a  patient  often  survives  the  most  terrible  accidents  of  the  head. 

f  Although  Zinn,  Fallopius,  Veslingius,  and  others,  consider  wounds  of  the  ce- 
rebellum as  curable,  and  have  cured  individuals  who  were  supposed  to  have  thi3 
part  of  the  brain  injured ;  and  although  the  illustrious  Baron  Haller  mentions, 
that  he  had  once  seen  the  cerebellum  schirrus  ;  yet  the  observation  of  Bohnin?, 
and  others,  who  have  wrote  expressly  on  the  subject,  that  these  wounds  are  almost 
inevitably  fatal,  cannot  be  considered  as  invalidated  by  those  solitary  instances  of 
recovery. 

\  The  medulla  oblongata  is  just  a  part  of  the  cerebellum,  and  is  of  the  same  im- 
portance to  the  living  system.  We  see  it  supporting  life  in  insects,  who  are  with- 
out a  brain,  and  in  acephalous  monsters.  Wounds  of  it  are  fatal  and  dangeroup, 
in  proportion  as  they  are  near  the  head ;  or,  in  other  word0,  according  to  the  value 
ff  the  nerves  which  originate  beneath  them. 


23 

These  elongations,*  or  nerves,  possess  a  degree  of  energy, 
or  vital  power,  in  themselves,  independent  of  what  they  re- 
ceive from  the  brain  as  their  source.  They  are  neither  more 
nor  less  than  continuations  of  the  brain,  possessing  the  same 
power,  and  endowed  with  a  similar  quality,  It  would,  in- 
deed, from  reflection,  independent  of  experiments,  be  reason- 
able to  conclude,  that  the  nervous  energy  must  be  diffused 
over  all  the  body,  although  it  resides  in  a  greater  proportion 
in  the  brain,  from  whence  it  is  sent  to  support  the  other 
parts  of  the  system-  In  genera!,  the  quantity  of  energy  in  a 
nerve  is  proportioned  to  its  size  ;  it  is  greatest  in  the  brain, 
and  less  in  all  the  elongations,  in  a  degree  correspondent  to 
their  magnitude. j  The  small  nerves  have  a  dependence 
upon  the  great,  and  these  again  upon  the  brain  :  An  universal 
connection  is  thus  established,  no  one  part  of  the  body  being 
of  itself  sufficient  for  living.i 

The  delicacy  of  the  nervous  system  is  proportioned  to  the 
perfection  of  the  animal ;  and,  therefore,  it  is  chiefly  by  ex- 
periments on  the  individuals  of  the  lower  ranks,  that  this  doc- 
trine is  to  be  confirmed.  At  the  same  time,  some  assistance 
may  be  derived  from  what  we  occasionally  observe  in  the 
more  perfect  animals.     We  find,  for  instance,  that  children 

*  Aristotle  believed,  that  the  nerves  originated  from  the  heart;  and  his  suc- 
cessors taught,  that  the  blood-vessels  which  proceeded  from  the  heart,  were  con- 
verted, in  the  brain,  into  nerves.  It  is  on  this  account,  says  Van  Horn,  that  in 
anger,  the  blood  boils,  and  the  eyes  flash  with  fire. 

t  We  must  carefully  distinguish  betwixt  energy  and  action,  tfhich  do  -not  al- 
ways correspond.  The  brain,  which  most  likely  contains  the  greatest  quantity  of 
energy,  considered  absolutely,  exhibits  less  action  than  many  small  nerves ;  for  I 
do  not  consider  the  operations  of  the  mind  as  an  action  of  the  nervous  energy  in 
the  brain.  Mind  and  nervous  energy  are  totally  different ;  and,  once  for  all,  I 
beg  to  mention,  that  I  consider  the  soul  or  spirit  as  di?tinct,and  altogether  out  of 
the  present  question  concerning  vital  power,  and  its  action*. 

t  Although  the  inherent  quantity  of  energy  appears  to  Correspond  to  the  quan- 
tity of  nervous  medulla,  yet  the  action  does  not,  being  gicatest  in  the  extremities, 
or  rather  almost  entirely  confined  to  the  extremities,  which  draw  their  energy 
from  the  trunks  These  seem  to  secrete  the  power,  whilst  the  extremities  «z- 
?en^  it. 


24 

have  been  known  to  grow  and  live  in  the  womb  without  any 
brain,  receiving  their  vital  energy  from  nerves  alone;  which 
proves,  that  a  brain  is  by  no  means  essential  to  the  mere 
presence  of  vitality  in  an  animal.     On  the  other  hand,  we 
observe,  that   particular  nerves  may  lose   their  energy,  al- 
though the  brain  remains  sound,  as  we  see  exemplified  in 
paraplegia  and  partial  palsy.     At  other  times,  we  find  both 
the  brain  and  the  nerve  sound,  but  the  connection  subsisting 
betwixt  them  destroyed ;  in  which  case  the  nerve  has  only 
its  own  inherent  energy,  and  derives  no  assistance  from  the 
brain,  or  parts  above.     This  is  daily  seen  in  curvature  of  the 
spine.*     The  doctrine  may  also  be  confirmed,  by  the  case 
of  a  gentleman,  who  was  paralytic  from  the  head  downward, 
but  the  heart  and  bowels  continued  their  action.     Here  the 
spinal  marrow  only  was  diseased ;  and  that  portion  of  the 
brain  which  gave  off  the  intercostal  and  sympathetic  nerves, 
as  well  as  those  nerves  themselves,  was  healthy.      But  it  is 
most  beautifully  proved,  by  the  well-known  experiments  of 
applying  zinc  and  silver  to  the  nerve  of  an  amputated  limb, 
by  which  we  produce  contractions  of  the  muscles,  and  make 
the  apparently  dead  member  move  upon  the  table.     It  has 
been  long  known,  that  if  we  tie  a  ligature  upon  the  phrenic 
nerve  of  a  dog,  the  motion  of  the  diaphram  ceases ;  but  if  we 
stimulate  the  nerve  below  the  compressed  spot,  by  stripping 
it  either  upward  or  downward  between  our  fingers,  the  con- 
traction of  the  diaphragm,  for  a  time,  returns.     By  experi- 
ments upon  the  amphibious  and  reptile  tribe,  the  doctrine  is 
ascertained  to  be  true  beyond  all  dispute.     It  is  well  known, 
that  a  frog  will  live,  for  a  couple  of  days,  after  his  head  is  cut 
off;  that  he  will  jump  about,  and  will  even,  if  we  may  credit 

*  It  is  necessary,  how  ever,  that  this  interruption  take  place  gradually,  in  order 
to  accustom  the  nerve  to  e  vert  itself,  if  I  may  use  the  expression,  independent  of  the 
brain:  For,  if  we  cut  the  nerve  suddenly,  we  find,  that  the  difference  betwixt  the 
energy  inherent  in  thenervo,  and  that  which  it  waswontto  receivefrom  the  brain, 
is  «o  great,  that  the  parts  cam  lot  exist .  The  change  is  too  great  and  too  sudden. 


25 

the  Abbe  Spallanzani,  return  to  the  embraces  of  his  mistress, 
if  the  decapitation  has  taken  place  during  the  payment  of  his 
addresses.  It  is  also  known,  that  if  we  divide  the  spinal  mar- 
row, the  crural  nerves  being  no  longer  assisted  by  the  parts 
above,  become  weakened,  having  only  their  own  energy,  and 
the  limb  is  palsied ;  but  still  there  is  energy  sufficient  to  con- 
tinue the  circulation ;  and  "  the  bones,  if  fractured,  will 
unite."  If  we  cut  a  frog  across,  we  may  make  the  legs  move 
for  hours,  by  applying  the  zinc  and  silver  ;  or,  if  we  suspend 
the  lower  half,  by  a  wire,  from  the  conductor  of  an  electrical 
machine,  we  shall,  by  taking  sparks  from  the  legs,  exhibit  a 
very  grotesque  dance. 

The  tortoise  will  live,  after  decapitation,  for  many  days  ; 
and,  if  we  may  credit  naturalists,  has  been  known  to  survive 
the  extraction  of  the  brain  for  half  a  year.  The  bodies  of 
some  serpents  will  move  about,  when  irritated,  even  after  be- 
ing deprived  of  the  head,  skin,  and  heart.  Kaau  tells  us  of  a 
cock,  who  run  thirty  feet  after  decapitation ;  and  many  other 
instances,  of  a  similar  nature,  might,  if  necessary,  be  added. 
From  all  these  facts,  it  appears,  that  the  nervous  system  is 
one  great  whole,  having  its  energy  universally  diffused  over 
it,  and  inherent  in  every  part. 

A  doctrine  similar  to  this  has  occurred  to  many,  and, 
among  the  rest,  to  the  ingenious  Dr.  Whyte ;  but  he  ascribes 
to  the  soul  what  is  here  attributed  to  the  nervous  energy  ; 
and,  by  this  theory,  is  obliged  to  involve  himself  in  metaphy- 
sical reasonings,  concerning  the  extensibility  of  the  soul,  as 
taught  by  Gassendi,  and  others.  According  to  him,  when  a 
muscle  is  removed  from  the  body,  and  placed  at  ten  yards 
distance  from  the  body,  the  soul  extends  to  it  over  all  that 
part  of  space,  and  enables  it  to  contract.  When  this  muscle 
dies,  then  we  must  either  suppose  that  part  of  the  soul  is  lost, 
or  that  it  retracts  itself  again  within  the  body;  which  being 
vor:.  tk  d 


2(J 

Jess  than  formerly,  must  have  a  greater  proportion  of  soul  > 
both  of  which  suppositions  would  be  ridiculous.* 

Of  the  Nervous  Energy. 

Many  have  undertaken  to  ascertain  the  precise  nature  of 
the  nervous  energy,  and  the  manner  in  which  it  is  produced ; 
but  I  apprehend,  that  no  argument  will  be  necessary  to  prove 
the  vanity  and  absurdity  of  the  attempt:  It  eludes  all  our  re- 
searches ;  it  does  not  come  under  the  cognisance  of  our 
senses ;  and  we  might  just  as  reasonably  attempt  to  describe 
and  comprehend  a  new  sense,  or  detail  the  intimate  nature  of 
an  unknown  substance. 

The  ancients  believed  this  energy  to  he  of  a  gaseous  na- 
ture, and  maintained,  that  it  was  formed  in  the  ventricles  of 
the  brain,  from  the  air  which  we  inspired.f  This  air,  ac* 
cording  to  some,  operated  in  part  indirectly,  through  the 
medium  of  the  lungs  ;  but  it  was  allowed  by  aU,  to  act  chief- 
ly, by  a  direct  ascent  to  the  brain,  through  the  cribriform  la- 
mella of  the  ethmoid  bone.  Those  who  were  resolved  to 
adopt  implicitly  whatever  the  ancients  desired  them  to  be- 
lieve, were  glad  to  forget  the  olfactory  nerve,  which  filled 
these  holes  up  completely,  and  chose  rather  to  remember  the 
pretended  experiment,  in  which  tobacco  was  found  to  tinge 
the  brain,  by  being  snuffed  up  the  nose.t  This  supposition 
being,  as  they  thought,  proved,  physiologists  began  to  push 
the  doctrines  of  the  ancients  still  farther  :  They  took  up  the 
conjecture  where  they  ended,  and  attempted  to  explain  the 
particular  nature  of  the  aeriform  principle.  Some  called  it 
a  very  Ihin  air,  impregnated  with  nitre ;  others,  a  mixture  of 
air,  sulphur,  and  saline  matter  :  And,  as  every  one  is  fond  of 

*  Vide  Whj-te's  Worksop.  202.  "  Of  the  Vital  and  other  Involuntary  Motion?  " 
f  Galen  de  Util.  Respir.  cap.  5. 
1  FracasBatus  d«  Cerebro,  p.  328. 


27 

making  his  own  discoveries  as  important  as  possible,  we  find 
Mayow  attributing  this  property  to  his  nitro-aerial  or  oxyge- 
nous principle.  This  supposition  was,  in  a  manner,  repeated 
by  Barbieri,  and  has,  of  late,  been  revived  by  Dr.  Girtanner, 
who  can  fill  bottles,  as  well  as  nerves,  with  this  principle  of 
life  and  irritability.  / 

Not  less  ridiculous  than  these  conjectures,  was  that  of 
Mistichelli,  who  imagined,  that  the  nervous  energy  was  pro- 
duced by  a  kind  of  fermentation  taking  place,  between  what 
he  called  the  sulphur  of  the  blood,  and  a  particular  kind  of 
air ;  or  the  conjecture  of  those  who  believed,  that  hartshorn 
was  the  true  nervous  spirit.* 

Those  who  attended  less  to  chemistry,  and  more  to  anato- 
my, disbelieved  these  notions,  and  taught  their  own  disciples, 
that  the  nervous  spirit  was  not  so  very  volatile  ;  that  it  bore 
a  more  near  resemblance  to  the  other  fluids  of  the  human 
body,  artd  consisted  entirely  of  a  finer  portion  of  the 
lymph.f 

The  Cartesians,  who  loved  wonders,  called  it  pure  flame, 
or  a  kind  of  neutral  substance  between  flame  and  air  ;J  whilst 
the  Newtonians,  forgetting  the  accuracy  which  mathematics 
might  have  taught  them,  imagined  their  aether  to  be  the  prin- 
ciple of  life.  The  supposition  which  Sir  Isaac  Newton 
threw  out,  in  the  form  of  a  query,  was  adopted  by  many,  and, 
amongst  others,  by  Dr.  Mead,  who  observes,  that  "  this  fluid. 
(the  nervous  energy,)  so  far  as  we  can  discover  by  its  effects, 
is  a  thin  volatile  liquor,  of  great  force  and  elasticity,  being  in- 
deed most  probably  a  quantity  of  the  universal  elastic  matter 
(aether,)  incorporateb!  with  fine  parts  of  the  blood,  separated 
in  the  brain,  and  lodged  in  the  fibres  of  the  nerves.     This  is 

*  Cheyne  in  the  Phil.  Princip.  of  Religion. 

t  Berger,  p.  269. 

t  Although  they  believed  this,  yet  they  were  foolish  enough  to  talk  of  valves 
in  the  nerves,  as  if  this  matter  could  be  obstructed  or  regulated  by  valvular  folds. 
Vide,  Descartes  de  Homine. 


28 

the  instrument  of  muscular  motion  and  sensatien,  a  great 
agent  in  secretions,  and  indeed  in  the  whole  business  of  the 
animal  economy."* 

Other  physiologists  rejected  this  conjecture,  concerning 
the  action  of  a  suppositious  principle,  and  referred  life  to  the 
operation  of  causes  with  which  they  were  better  acquainted. 
Magnetism  and  electricity  were  too  wonderful  agents  to  be 
overlooked :  The  last  was  by  many  supposed  to  constitute 
the  nervous  energy,  and  even  of  late  we  find  some  support- 
ing a  similar  doctrine.f 

Partly,  perhaps,  from  the  absurdity  of  these  notions,  and 
partly  from  chimerical  principles,  the  very  existence  of  a 
nervous  fluid  was  denied,  and  the  agency  of  the  soul  or  mind 
became  more  attended  to.  That  the  phenomena  of  life  de- 
pended upon  the  rational  soul,  without  the  assistance  of  any 
other  energy,  was  the  opinion  of  some  ;  whilst  others  allowed 
the  existence  of  a  peculiar  power  in  the  nerves,  but  main- 
tained, that  this  was,  to  the  utmost  extent,  under  the  con- 
troul  of  the  soul,  which  presided,  as  an  aiitocrator,  with  wis- 
dom, over  all  the  operations  of  the  living  body. 

Having  given  up  the  doctrine  of  a  nervous  fluid,  it  be- 
came necessary  to  explain  how  the  nerves  performed  their  va- 
rious offices,  particularly  those  of  motion  and  sensation,  and 
how  external  stimuli  acted  on  them.     This  they  endeavoured 

*  Mead's  Works,  8vo.  p.  14. 

f  See  the  experiments  of  Valli,  Galvani,  and  others,  on  this  subject.  "  The 
similarity  of  the  texture  of  the  brain  to  that  of  the  pancreas,  and  some  other 
glands  of  the  body,  has  induced  the  inquirers  into  this  subject  to  believe,  that  a 
fluid,  perhaps  much  more  subtle  than  the  electric  aura,  is  separated  from  the  blood 
by  that  organ,  for  the  purposes  of  motion  and  sensation.  When  we  recollect  that 
the  electric  fluid  itself  is  actually  accumulated  and  given  out  voluntarily  by  the 
torpedo  and  gymnotus  electricus  ;  that  an  electric  shock  will  frequently  stimulate 
into  motion  a  paralytic  limb ;  and,  lastly,  that  it  needs  no  perceptible  tubes  to 
convey  it,  this  opinion  seems  not  without  probability  ;  and  the  singular  figure  of 
the  brain  and  nervous  system  seems  well  adapted  to  distribute  it  over  every  part 
of  the  body." 

Darnin's  Zoonomia,  vol.  i.  p.  10. 


29 

to  do,  upon  the  mechanical  supposition  of  tremors  and  oscil- 
lations, which  were  excited  by  the  impressing  cause,  and  pro- 
pagated along  the  whole  course  of  the  nerve.  Much  time  was 
spent  in  examining  the  fibres  of  the  nerves,  and  their  direc- 
tion; nor  is  there  almost  any  course  or  direction  which  was 
not  attributed  to  them.* 

Another  set  of  physiologists  united  the  two  theories,  and 
admitted  both  the  existence  of  a  nervous  fluid,  and  the  action 
of  tremors.f 

Concerning  the  absurdity  of  all  these  opinions,  I  think  it 
unnecessary  to  make  any  observation.  The  doctrines  sur- 
vived, for  only  a  very  little  time,  their  inventors ;  and  th& 
more  intelligent  part  of  investigators  soon  came  to  confess 
their  ignorance  of  the  nature  of  this  principle. 

If  the  notions  which  the  older  physicians  entertained  con- 
cerning the  nature  of  the  nervous  energy  were  erroneous,  we 
are  not  to  expect  that  their  explanation  of  its  operation,  or 
their  application  of  their  knowledge  to  the  cure  of  diseases. 
should  be  more  perfect.  Their  systems  were  full  of  quick 
motions  and  £  slow  motions  of  the  nervous  spirit,  and  tensions. 
and  contractions,  and  relaxations  of  the  nerves  themselves, 
and  fermentations,  explosions,  impulses,  and  pre-established 
harmonies.  We  may  wonder  how  this  could  be  suffered  by 
men  of  sense,  or  how  they  could  possibly  explain  diseases  oc 

*  Some  supposed  that  the  nerve  consisted  of  spiral  fibres,  which  could  shorten 
and  elongate ;  others,  that  it  had  rugae,  which  might  be  made  greater  or  smaller ; 
and  that  on  this  depended  the  action  of  the  nerves.  Whenever  the  nerve  was 
tight,  than  the  sensation  was  acute ;  and  vice  versa. 

f  This  opinion  has  been  in  part  revived  by  Dr.  Darwin,  who  supposes  that  the 
vital  spirit  produces  motions  or  contractions ;  and  builds  his  theory  on  the  differ- 
ent kinds  of  motion. 

t  Part  of  the  nervous  spirit  was,  in  their  opinion,  exhaled  into  the  cavities 
of  the  body,  or,  by  insensible  transpiration,  from  the  body  ;  the  rest  was  re- 
turned from  the  nerves,  by  the  veins,  to  the  heart,  and  sent  from  thence  to 
the  brain.  Others  supposed,  that  it  passed  into  glands,  or  was  condensed  into 
lyniph,  and  thus  returned  to  the  head  through  the  medium  of  the  heart.  See 
the  Works  of  Regius,  Segerus,  Gavet,  Lancui,  Targirus,  &c. 


30 

these  principles ;  but  the  wonder  ceases,  when  we  know  that 
the j  founded  their  system  of  pathology  more  on  the  blood 
and  imaginary  humours,  than  on  the  nerves :  their  doctrines 
were  either  chemical  or  mechanical,  and  they  knew  nothing 
of  the  peculiar  and  varied  action  of  the  nervous  system. 

Concerning  the  true  and  precise  nature  of  the  nervous 
energy,  nothing  ever  can  be  said ;  because  it  never  can  come 
under  the  cognizance  of  our  senses;  and  even  concerning  its 
production  and  operations  a  very  great  deal  is  conjectural. 
We  know,  however,  that  there  is  such  a  principle,  and  that 
this  principle,  by  the  application  of  certain  stimuli,  exhibits 
certain  actions  or  operations  which  are  essential  to  life,  and  in 
which  it  consists.  These  actions,  in  the  aggregate,  may  be 
called  the  natural  and  healthy  action*  of  the  system  ;  and  the 
presence  of  this  action  is  absolutely  requisite  for  the  continu- 
ance and  support  of  the  energy  ;f  for,  whenever  the  action 
becomes  changed,  either  in  degree  or  nature,  weakness  is  the 
consequence  ;  and  this  weakness  is  proportioned  to  the  differ- 
ence betwixt  the  diseased  and  natural  action  of  the  system. 

*  It  is  not  easy  to  give  such  a  definition  of  the  natural  actions  as  shall  not  be 
liable  to  be  misunderstood.  It  does  not  consist  of  digestion,  secretion,  kc.  con- 
sidered as  a  group  of  separate  and  distict  functions,  but  in  a  peculiar  inde- 
scribable condition,  which  exists  in  health,  and  of  which  these  operations  are 
effects,  rather  than  parts :  still,  as  the  right  performance  of  all  these  functions 
depends  upon  the  natural  and  healthy  action  of  the  system,  these,  taken  col- 
lectively, may  give  some  idea  of  this  action.  Part  of  the  natural  action  con- 
sists in  the  renewing  or  producing  of  the  nervous  energy,  which  is  to  be  con- 
sidered as  a  species  of  secretion. 

+  It  may  be  said,  in  objection  to  the  supposition  that  the  renewal  of  the  en- 
ergy is  an  immediate  and  direct  effect  of  the  natural  action,  and  flows  neces- 
sarily from  it,  that,  were  this  the  case,  an  increase  of  the  natural  action  should 
not  produce  weakness  in  the  end.  But  this  idea  proceeds  from  not  rightly 
understanding  the  natural  action,  which  is  not  a  distinct  assemblage  of  func- 
tions, but  a  general  and  peculiar  condition,  of  which  these  functions  make  a 
part  ,  and,  therefore,  although  an  increase  of  a  particular  function,  such  as 
muscular  motion,  does  expend  more  energy  than  is  produced,  and  consequent- 
ly weakens,  yet  a  general  increase  of  natural  action,  if  it  be  not  to  such  a 
degree  as  to  change  its  nature,  and  thus  impair  it,  does  augment  the  quantity  d 
-.nepgy,  and  produces  strength ;  if  it  be  changed,  then  it  weakens. 


31 

The  brain  has,  by  almost  every  physiologist,  been  consi- 
dered as  the  preparer  and  source  of  this  energy  ;  and,  even 
in  the  present  day,  is  ranked  amongst  the  secreting  glands. 
That  this  energy  exists  in  the  brain  and  nerves,  and  that  it 
exists  in  greater  and  less  quantity,  at  different  times,  is  un- 
doubted. The  embryo  contains  less  energy  than  the  child, 
and  the  child  much  less  than  the  adult.  He  who  is  reduced, 
by  abstinence  and  long  sickness,  has  much  less  energy  than 
the  healthy  and  robust  man.  These  facts  require  no  proof; 
for  the  imbecility  of  the  natural  action  of  those  people,  and 
their  inability  to  support  disease,  proves  it  beyond  doubt.* 
it  is  necessary,  however,  here  to  remark,  what  will  be  after- 
wards more  folly  explained,  that  we  are  not  to  confound  an 
appearance  or  feeling  of  weakness  with  real  and  absolute  di- 
minution of  energy  ;f  because  certain  temporary  morbid  ac- 
tions may  take  place,  which,  by  their  diminution  of  the  na- 
tural action,  for  a  time,  give  the  appearance  of  weakness. 
This  proceeds  sometimes  from  a  simple  diminution  or  sus- 
pension of  natural  action ;  at  other  times,  from  the  energy 

*  It  is  likewise  certain,  that  particular  parts  of  the  body  have  less  energy 
than  others,  and,  consequently,  less  action.  A  part  is  only  capable  of  acting 
by  means  of  its  energy ;  and  the  degree  of  the  one  must  always  correspond  to 
that  of  the  other.  The  capability  of  supporting  disease  is  proportionate  to  the 
strength  or  degree  of  natural  action;  hence  children  bear  disease  worse  lha» 
adults,  and  weakened  parts  worse  than  those  which  are  strong ;  at  the  same 
time,  we  cannot  expect  to  see  the  diseased  action  so  great  in  them  as  in  the 
strong,  although  it  is  such  as  to  destroy  them  ;  because  the  energy  which  is  to 
support  it  is  less.  Still,  although  it  be  not  considered  as  absolutely  a9  strong 
or  great,  yet,  relatively  considered  with  regard  to  the  power,  it  is  greater. 

f  Whenever  the  natural  action  is  lessened,  weakness  is  felt ;  and  this  is  more 
observable,  in  proportion  as  the  diminution  is  sudden.  Emotions  of  the  mind, 
and  many  other  causes,  by  lessening  suddenly  the  natural  action  of  the  sys 
tem,  produce  syncope  ;  but,  in  a  few  minutes,  the  person  is  often  as  strong  a* 
ever.  Here  we  cannot  suppose  a  sudden  loss  and  restoration  of  energy  ;  it  was 
only  the  action  which  was  affected;  but,  had  this  action  continued  for  any 
considerable  time,  then  real  lo»s  of  energy  would  have  followed,  upon  the  prind- 
nlea  already  laid  down 


32 

being  employed  in  an  action  dissimilar  to  the  healthy  one. 
At  the  same  time,  if  this  action  does  continue  for  any  con- 
siderable time,  real  diminution  of  energy  will  take  place  ;  be- 
cause a  certain  action  is  necessary  for  the  support  of  the  en- 
ergy;  and,  in  health,  this  action  always  bears  an  exact  pro- 
portion to  the  degree  of  energy.  The  action  of  the  energy 
is  often  very  suddenly  lessened,  in  which  case,  weakness  or 
syncope  is  the  consequence ;  and  often  it  is  as  suddenly  re- 
stored, in  which  case  our  strength  returns.  Energy  may  be 
suddenly  lessened,  but  it  never  can  be  suddenly  restored. 

This  energy  is  not  produced  in  consequence  of  the  strucr 
ture  of  the  nerve,  or  by  any  power  proper  to  the  nerve,  and 
necessarily  connected  with  a  medullary  texture.  If  it  de- 
pended on  structure  alone,  man  should  live  as  long  as  his  fa- 
bric remained  unimpaired ;  and  if  it  depended  on  any  pecu- 
liar power  of  the  nerves,  distinct  from  the  action  of  the  energy 
itself,  we  must  acknowledge  a  new  principle  ;  we  must  ob- 
serve its  operations,  and  ascertain  what  causes  influence  it, 
which  will  only  multiply  difficulties. 

It  may  perhaps  be  supposed,  that  the  energy  remains  al- 
most always  the  same,  and  that  its  action  or  operation  only 
changes  ;  but,  in  this  case,  whenever  any  action  ceased  or 
decreased,  the  quantity  of  energy  should  accumulate,  which 
is  an  absurd  idea.  .  Some  suppose  an  accumulation  of  the 
living  principle  ;  but  the  idea  is  ridiculous  ;  for  energy  can 
never  exist  without  action.  Action  requires  energy ;  it  con- 
sumes the  energy,  which  must  be  replaced.  If  this  were 
not  the  case,  we  need  only  excite  the  action  by  stimuli,  and 
life  should  go  on.  As  long  as  the  blood  circulated,  action 
and  life  should  be  kept  up,  even  without  food.  Death  indeed 
would  at  last  take  place,  from  want  of  materials  to  supply  the 
body,  considered  mechanically  ;  but  still  the  man  should  live 
for  a  long  time,  and  until  he  consisted  of  little  else  than  bones, 
nerves,  and  vessels.  Man  might,  upon  this  supposition,  be 
rendered  immortal. 


33 

Of  the  Blood. 

For  the  support  and  production  of  the  nervous  energy,  a 
certain  substance,  namely,  arterial  blood,  is  requisite.  This 
fluid,  by  its  circulation,  not  only  acts  as  a  natural  stimulus  to 
the  nerve,  exciting  and  supporting  its  action,  and  thus  ena- 
bling the  energy  to  subsist,  but  it  also  affords  the  materials 
from  which  the  energy  is  drawn.  It  was  formerly  mention- 
ed, that  there  is  nothing  which  can  be  called  truly  dead ; 
that  a  vital  principle  pervades  every  substance,  and  extends 
its  influence  over  the  whole  universe.  This  principle,  it  was 
mentioned,  exists,  in  different  degrees  of  delicacy,  in  the 
different  classes  of  nature,  and  exhibits  a  regular  gradation  of 
perfection,  in  the  different  individuals.  Common  matter  pos- 
sesses a  peculiar  kind  of  life  :  When  this  matter  is  taken  into 
the  vegetable,  not  only  its  organization,  but  also  its  life,  is 
changed,  and  we  observe  a  very  different  appearance,  both  in 
the  mechanical  and  vital  system ;  but,  when  the  vegetable  is 
destroyed,  then  it  becomes  again,  both  in  its  substance  and 
life,  the  same  with  common  matter.  When  the  vegetable  is 
taken  into  the  animal  system,  we  likewise  find  a  change,  both 
in  life  and  texture.  We  have  then  a  certain  gradation,  which 
remains  uniform  ;  the  material  part  of  the  one  class  forms  the 
material  part  of  the  other,  and  the  vital  principle  of  the  one 
forms  the  vital  influence  of  the  other.*  This  change  uni- 
formly begins  in  the  fluids.  In  the  vegetables,  the  sap,  and 
in  animals,  the  chyle,  which  forms  the  blood,  is  the  first  step 
towards  the  change  of  life.  These  substances  consist  of  mat- 
ter, having  a  life  proper  to  itself,  differing  as  much  from  the 
active  principle  of  common  matter,  as  it  does  from  the  pecu- 

*  It  must  here  be  observed,  that  there  is  a  material  distinction  betwixt  life  and 
soul,  or  mind :  They  differ  fisserttially  in  their  nature  and  operations. 
vol.  r.  v 


34 

liar  life  of  the  individual,  considered  as  an  organized  body, 
and  a  whole. 

From  the  blood  is  formed  the  material  part  of  the  animal, 
and  likewise  its  life,  or  nervous  energy.  Neither  the  mate- 
rial part  of  vegetables  can  be  converted  directly  into  animal 
substance,  nor  their  vital  principle  into  nervous  energy : 
There  must  be  intermediate  steps,  and  these  are  the  chyle 
and  blood.  Vegetables,  when  alive,  differ  from  animals,  in 
composition,  in  organization,  and  in  the  qualities  of  their  life. 
When  taken  into  the  stomach,  and  in  a  state  of  digestion, 
they  differ  from  animal  substances,  in  the  same  circumstances  ; 
but,  when  the  living  power  of  the  animal  has  begun  to  operate 
in  the  formation  of  chyle,  the  distinction  no  longer  subsists, 
at  least  to  the  same  extent.  A  new  substance  is  formed, 
and  from  this  another,  which  is  the  blood  ;  and  from  this  an 
organized  substance  results,  possessed  of  a  more  intricate 
structure,  and  a  higher  species  of  life.* 

Besides  this  source  of  the  living  principle,  arising  from  the 
conversion  of  food  into  blood,  and  the  consequent  change  of 
the  one  kind  of  life  into  the  other,  the  blood  likewise  derives 
vitality  from  the  air,  during  respiration.  It  may  be  consider- 
ed as  a  fact,  that  whenever  matter  becomes  part  of  a  vegetable 
or  animal,  its  active  principle  likewise  becomes  changed  or 
elevated  into  the  specific  life  of  the  individual  of  which  it  be- 
comes a  part.  Now,  we  know  that,  in  the  course  of  24 
hours,  about  8640   cubic  inches  of  oxygenf  are  combined 


*  Every  part  of  the  body  dies,  and  rs  replaced.  If  even  a  small  part  be  re- 
moved, it  is  reproduced,  and  the  new  matter  possesses  the  properties  of  the  old 
The  nerves  themselves,  if  divided,  will  unite;  and  the  uniting  substance  is,  to  aH 
intents  and  purposes,  nerve.  See  Dr.  Haighton's  Paper  in  the  Phil.  Trans,  on  the 
Reproduction  of  Nerves. 

f  It  is  computed  by  chemists,  that,  besides  the  portion  of  oxygen,  which  com- 
bines with  the  carbone  and  hydrogen,  in  respiration,  360  cubic  inches  of  that  air 
disappear  in  an  hour.  This  oxygen  changes  its  state  in  the  blood ;  for  I  know  of 
no  experiment  which  proves,  that  it  is  found  in  a  gaseous  state  in  the  blood.  This 
opinion,  of  respiration  being  subservient  to  the  production  of  vitality,  is  also 
adopted,  in  one  respect,  by  Dr.  Darwin,  who  supposes,  that  an  ethereal  fluid  i* 


35 

with  the  blood,  and  become  a  constituent  part  of  it,  which 
affords  a  very  abundant  supply  of  vitality.  The  constant 
action  of  the  system  requires  a  much  more  frequent  renewal 
of  life,  than  we  can  suppose  to  be  yielded  by  the  food,  when 
converted  into  chyle  and  blood.  We  likewise  find,  that,  in 
many  diseases,  no  food,  or  almost  none,  is  taken  into  the  sto- 
mach, for  weeks,  although  the  action  of  the  system  be  very 
great.*  Respiration  is  a  constant  and  uniform  source,  from 
which  the  expenditure  of  energy  can  be,  in  some  respect, 
supplied ;  because  the  active  principle,  in  oxygen,  is  thus 
conveyed  to  the  blood,  during  its  combination  with  that 
fluid  ;  but  respiration  alone,  without  food,  is  not  adequate  to 
the  necessities  of  man,  both  because  the  life  thus  attained  is 
not  equivalent  to  the  demand,  and  also  because  the  materials 
of  nourishment  are  withheld.  The  vitality  yielded  by  the 
food  is,  if  I  may  so  speak,  more  permanent,  and  is  united 
with  the  structure  of  the  body,  when  the  deposition  of  new 
matter  is  made  by  the  blood.  The  vitality  furnished  by  the 
air  seems  to  be  yielded  to  the  nerves,  during  the  course  of  cir- 
culation, for  the  immediate  performance  of  the  actions  of  the 
system. 

As  the  elevation  of  life,  or  the  conversion  of  the  lower 
into  the  higher,  begins  in  a  fluid  state,  so  also  does  its  des- 
cent. The  solid  parts  of  animals  are  continually  changing 
into  a  fluid  or  lymph,  which  is  thrown  out  of  the  body,f  as 

yielded  by  the  air  to  the  blood,  and  secreted  from  it  again  by  the  brain. 
Zoonomia,  Vol.  1.  p.  471. 

*  The  drink  used  during  illness,  may  reasonably  be  supposed  to  assist  in  the  pro- 
duction of  vitality;  but  it  cannot  of  itself  yield  enough.  By  being  long  boiled 
with  a  little  farinaceous  substance,  water  yields  more  nourishment,  and  more  life, 
than  either  it  or  the  farina  would  do  separately  and  unboiled  j  but,  in  sickness,  it 
is  not  employed  in  this  form.    See  Goun,t  Rumford's  Essays. 

f  This  lymph  is,  along  with  the  chyle,  poured,  by  a  common  trunk,  into  the 
subclavian  vein.  It  is  then,  after  passing  through  the  lungs,  circulated  along  the 
body,  and  is,  most  probably,  the  substance  from  which  the  different  excretions  are 
formed :  It  is  thus  thrown  out  of  the  body,  and  begins  to  assume  new  states  and 
conditions,  and  to  answer  other  purposes,  in  the  general  and  extensive  operations 
of  nature, 


36 

unfit  again  to  become  organized  animal  substance,  until  it  has 
undergone  new  changes,  and  been  converted  either  into  vege- 
table matter,  or  animal  substance  of  a  lower  degree.  Even  the 
nerves  themselves  terminate  directly  in  a  soft  and  fluid  mat- 
ter ;  and  perhaps  it  is  only  when  the  nervous  energy  is  leav- 
ing the  body,  that  it  is  capable  of  action ;  at  least,  we  find, 
that  action  is  uniformly  attended  with  an  expenditure  of 
energy ;  and  the  greater  the  action,  the  more  speedy  is  the 
loss  of  energy :  We  likewise  know,  that  it  is  only  the  ex- 
tremities of  nerves  which  act. 

I  have  said,  that  for  the  production  of  this  energy,  and  the 
support  of  its  action,  the  presence  of  arterial  blood  is  neces- 
sary. This  is  one  of  the  natural  stimuli  to  the  system,  and 
excites  those  operations  of  the  nervous  energy  which  are  ne- 
cessary for  life,  and  which,  in  the  aggregate,  are  called  the 
natural  action.  This  action  is,  in  common  language,  called 
life,*  whilst  the  energy  which  produces  it,  being  unseen,  is 
overlooked.  The  continuance  and  presence  of  this  action,  is 
necessary  for  the  preservation  of  the  energy  in  the  body,  and 
for  its  production.  Arterial  blood,  then,  is  of  the  utmost  im- 
portance, as  it  not  only  affords  the  material  from  which  life  is 
drawn,  but  also  is  one  great  cause  or  exciter  of  that  series  of 
operations,  which  are  necessary  for  the  renewal  of  the  ener- 
gy, and  its  preservation  in  the  system. 

This  fluid  has,  at  all  times,  received  particular  attention 
from  physicians,  and  its  composition  has  been  examined  with 
more  accuracy  than  perhaps  was  necessary  for  the  practice 
of  physic.  But,  as  formerly  the  systems  of  pathology  were 
founded  almost  entirely  on  the  different  states,  real  or  sup- 
posed, of  the  blood,  we  cannot  wonder  at  the  attention  which 
was  paid  to  it.  Notwithstanding  the  many  observations  which 

*  This  expression  came  to  be  used,  from  observing,  that  whenever  this  action 
ceased,  the  body  was  dead.  In  the  same  way,  we  apply  the  word  heat  to  the 
sensation  or  action  which  it  produces,  oftener  than  to  the  principle  which  causes 
it,  which  of  itself  is  not  hot. 


37 

were  made  upon  this  fluid,  and  the  various  opinions  whit  li 
have  prevailed  concerning  it,  it  is  only  of  late  that  i(  has  been 
supposed  to  differ  from  common  matter,  or  to  possess  any 
living  principle. 

Mr.  Hunter,  who  was  the  first  who  taught  that  the  blood 
was  alive,  founded  his  opinion,  not  upon  general  reasonings  on 
the  nature  and  extensive  operations  of  a  living  principle,  or  up- 
on the  necessity  of  the  thing,  but  upon  the  observation  of  cer- 
tain particular  phenomena,  and  especially  on  the  coagulation 
of  the  blood.  This  living  principle  he  supposes  to  be  the 
with  that  of  the  rest  of  the  body,  and  that  something  similar 
to  the  brain  is  distributed  through  the  blood,*  which  he  calls 
the  diffused  matter  of  life.  This  conjecture  cannot  be  ad- 
mitted ;  because,  in  the  first  place,  it  supposes,  that  life  de 
pends  upon  a  particular  substance  or  species  of  matter;  and, 
in  the  second,  we  cannot  see  how,  or  by  what  power,  this  sub- 
stance is  to  be  formed  in  the  blood.  I  have  already  mention- 
ed my  idea  of  life,  and  its  gradation  ;  and  also,  that  the  blood 
seems,  in  a  perfect  animal,  to  be  the  first  step  toward  the 
conversion  of  common  and  vegetable  matter  into  a  substance 
possessed  of  animal  life  ;  but  that  this  life  differs  as  much 
from  the  peculiar  life  of  the  animal,  as  it  does  from  that  of 
the  matter  from  which  it  is  formed.     Blood  is  to  be  consider- 


*  «  J  would  consider,  that  something  similar  to  the  subrtnnce  of  the  brain  ii 
diffused  through  the  body,  and  even  contained  in  the  blood,  and  between  this  and 
the  brain  the  communication  is  kept  up  by  nerves."  Hunter  on  the  Blood  and 
Inflammation,  p.  89. — Are  we  then  to  consider  that  the  brain  is  a  mass  of  life, 
and  that  a  similar  matter  is  diffused  over  every  part  of  the  body,  and  floats  in  the 
blood;  that  the  nerves  are  quite  different  in  their  nature  from  the  brain,  and  con- 
sist of  different  materials,  and  are  endowed  with  a  different  and  distinct  power  or 
principle,  acting  merely  as  connecting  lines  betwixt  the  life  of  the  brain  and  the 
life  of  the  body,  or  literally  as  chordae  internuntise  ?  Does  life  indispensably  re- 
quire, for  its  presence  and  existence,  something  similar  to  the  substance  of  the 
brain  p  and  does  it  exist  wherever  this  medulla  is  to  be  found :'  Do  we  observe  any 
thing  like  this  in  plants?  Do  we  see  it  in  muscles,  in  ligaments,  in  bones ?  or  h:n 
it  ever  been  detected  in  the  blood  ?  Vitality  may  exist  in  substances,  with  very 
different  structures  and  organization;  and  I  have  already  mentioned,  that  the 
living  principle  itself  Varies  very  much  in  different  individuals  and  classes. 


38 

ed,  in  one  respect,  as  extraneous  to  the  body,  operating  and 
exciting  to  action  as  an  extraneous  body,  and  yet  possessed 
of  powers  which  show  it  to  be  endowed  with  a  peculiar  life. 
We  are  to  consider  it  in  Iwo  views  ;  first,  absolutely,  as  a 
fiving  animal  substance,  having  peculiar  properties,  and  con- 
sisting of  different  parts,  kept  together  by  life,  and  separat- 
ing, when  dead  or  dying :  Second,  relatively,  as  the  source 
of  increase  and  nutrition,  and  as  making  a  part  of  the  animal 
body,  acting  upon  it  as  a  stimulus,  and  being  itself  acted  upon 
by  the  vessels  which  contain  it.  This  reciprocal  action  and 
reaction  is  absolutely  necessary  for  the  preservation  of  each; 
for,  if  either  fail,  both  die.  As  long  as  the  blood  is  alive  and 
perfect,  it  produces  the  life  of  the  animal,  and  supports  its 
action ;  and,  as  long  as  the  animal  and  its  vessels  are  living 
and  healthy,  the  blood  is  kept  perfect  and  alive.  When  the 
animal  becomes  diseased,  the  life  of  the  blood  becomes  also 
affected,  and  its  peculiar  quality  is  injured.  The  proper  cha- 
racteristic of  blood,  considered  absolutely  as  a  living  sub- 
stance, is  its  tendency  to  become  solid,  or  coagulate.  If  its 
vitality  be  not  previously  injured,  it  uniformly  becomes  firm, 
and  its  parts  separate,  as  soon  as  it  is  removed  from  the  ac- 
tion of  the  vessels  ;  and,  whenever  this  coagulation  takes 
place,  it  ceases  to  be  blood ;  it  dies.  Mr.  Hunter  supposes, 
that  this  coagulation  is  to  serve  a  useful  purpose  with  regard 
to  the  body,  and  particularly,  lhat  it  becomes  the  means  of 
nourishment :  But  nourishment  and  increase  depend  upon  a 
much  nicer  process ;  and  coagulation  never  can,  and  never 
does,  serve  any  useful  purpose,  otherwise  than  mechanically' 
stopping  a  hemorrhage ;  in  which  case,  it  is  precisely  similar 
to  any  other  dead  body ;  and,  whenever  coagulation  does  take 
place,  it  becomes  absolutely  useless  to  the  animal,  in  any 
other  point  of  view,  and  can  no  more  serve  the  purposes  of 
blood,  than  the  curd  of  milk  can.  Mr.  Hunter,  however,  is 
of  a  very  different  opinion ;  for  he  believes,  that  the  coagu 


39 

lum  is  still  alive,  and  possessed  of  the  power  of  action  within 
itself;  that  it  can  form  vessels,  unite  itself  to  the  surrounding 
parts,  and  assifme  actions  and  appearances  according  to  the 
nature  of  the  surrounding  parts.  "  The  moment  it  is  at  rest, 
(says  he,)  it  begins  to  form  itself  into  a  solid,  and  changes  in- 
to this  or  that  particular  kind  of  substance,  according  to  the 
stimulus  of  the  surrounding  parts,  which  excite  this  coagulum 
into  action,  and  make  it  form  within  itself,  blood-vessels, 
nerves,"*  &c.  If  this  were  the  case,  an  aneurism  ought 
never  to  burst ;  because,  when  the  blood  coagulates,  the  old 
coat  of  the  vessels  ought  to  assimilate  it  into  a  new  one. 
Every  observation  confirms  the  opinion,  that,  when  the  blood 
coagulates,  it  dies ;  but  how  or  why  it  does  coagulate,  never 
can  be  ascertained,  more  than  how  or  why  other  actions  are 
performed,  the  utility  of  which  we  do  not  clearly  discern. 
Arterial  blood  coagulates  rapidly,  and  into  a  mass  :  Veinous 
blood  coagulates  slower ;  the  serum  separates  freely,  but  the 
red  globules  are  mixed  with  the  lymph.  In  some  diseases,  it 
is  still  slower,  and  a  buffy  crust  is  formed  from  the  separation 
of  the  globules.  In  others,  it  never  takes  place  ;  the  blood, 
from  the  action  of  the  body,  being  almost  deprived  of  its  vi 
tality,  before  it  can  come  into  a  state  of  rest.  This  we  see  in 
the  effects  of  great  fatigue,  lightning,  poisons,  bad  fevers,  .S:c 
The  complexity  of  the  vascular  system  appears,  in  every 
animal,  to  be  proportioned  to  the  perfection  of  the  nervous 
system ;  and  the  purity  of  the  blood  uniformly  corresponds  to 
the  delicacy  of  the  living  principle.  It  would  be  useless  here 
to  mention  all  the  mechanical  variations  which  take  place  in 
the  heart  and  vessels  of  different  animals :  It  will  be  sufficient 
to  observe  the  particular  conformation  which  affects  the  puri 
ty  of  the  blood.  In  every  animal,  where  the  living  principle 
is  naturally  of  a  low  degree,  (by  which  I  mean,  of  a  kind  inca- 
pable of  exhibiting  the  actions  of  an  animal,  in  the  perfect 

*  Hunter  on  the  Blood,  &c.  p.  86. 


40 

manner  in  which  they  are  performed  in  man,)  the  blood  i* 
impure. 

In  the  frog,  we  find  a  hearl,  consisting  of  one  auricle  and 
one  ventricle  :  The  blood,  being  returned  from  the  body  by 
the  veins,  goes  into  the  auricle,  and  from  thence  into  the  ven- 
tricle: This  sends  out  a  large  trunk,  which  soon  divides  into 
two :  These  again,  shortly  after  the  first  division,  subdivide 
into  other  two  branches  :  One  of  these  branches,  on  each  side, 
goes  to  the  lungs,  and  the  other  turns  down,  to  join  Avith  the 
one  arising  from  the  other  side :  These  last  uniting,  form  a 
large  aorta :  The  branches,  which  are  distributed  on  the  lungs, 
or  bladders  of  air,  carry  their  blood  thither,  from  which  it  is 
returned  into  the  auricle.  But  I  have  already  said,  that  all  the 
veinous  blood  from  the  body  was  also  returned  to  the  auricle  : 
There  must,  therefore,  be  in  the  heart  a  mixture  of  arterial 
blood  from  Ihe  lungs,  and  veinous  blood  from  the  body;  and 
it  is  this  impure  blood  which  circulates  in  the  arteries,  and 
supplies  the  body. 

In  the  turtle,  we  have  distinctly  two  auricles  and  two  ven- 
tricles, forming  a  double  heart,  similar,  in  this  respect,  to  the 
heart  of  man  ;  but,  as  these  two  ventricles  communicate  by  a 
hole  in  their  septum,  they  are  to  be,  in  reality,  considered 
only  as  one  cavity.  From  the  right  ventricle,  or,  more  pro- 
perly speaking,  the  right  side  of  the  joined  ventricle,  arise  the 
aorta  and  pulmonary  artery ;  the  one  supplying  the  body, 
the  other  running  directly  to  the  lungs,  from  which  the  blood 
is  returned,  by  the  pulmonary  vein,  into  the  left  auricle ; 
from  this  it  is  sent  into  the  left  ventricle,  and  thence,  through 
the  hole  in  its  septum,  into  the  right  ventricle  ;  so  that,  set- 
ting aside  all  this  round-about  course,  we  may  say,  that  the 
blood  is  returned  from  the  lungs  into  the  right  ventricle.  The 
blood,  again,  which  is  sent  out  by  the  aorta,  is  returned,  by 
the  vena  cava,  into  the  right  auricle,  and  from  this  into  the 
tight  ventricle,  Avhere  it  meets  with  the  blood  from  the  lungs. 


41 

There  is,  then,  a  mixture  of  veinous  and  arterial  blood  in  the 
turtle,  just  as  in  the  frog ;  and  this  mixture  is  sent  again,  in 
part,  through  the  lungs,  and  the  rest  through  the  body. 

In  the  crocodile,  the  same  happens ;  only,  the  two  ventri- 
cles have  no  septum,  but  form  one  bag,  without  any  division. 

The  consequence  of  this  construction,  in  these  animals,  is, 
that  the  blood,  which  is  sent  to  the  lungs,  is  never  entirely 
veinous,  but  partly  veinous  and  partly  arterial,  by  which  the 
supply  of  air  will  last  longer,  and  the  animal  require  to  breathe 
less  frequently.  But,  secondly,  the  effect  of  this  construc- 
tion, and  the  consequent  impurity  of  the  blood  upon  the  sys- 
tem, is,  that  the  life  of  the  animal  is  of  a  less  delicate  nature, 
than  that  of  those  animals,  where  the  blood  is  pure :  Their 
action  is  not  raised  to  such  a  degree,  as  in  the  higher  classes; 
and  all  the  operations  of  their  system  are  of  a  lower  nature. 
This,  which  is  an  imperfection  in  one  sense,  is,  however,  a 
degree  of  perfection,  greater  than  We  find  in  man,  if  we  view 
life  only  with  regard  to  its  preservative  powers ;  for  those 
animals,  whose  life  is  of  so  low  a  kind,  that  it  is  not  suscepti- 
ble of  quick  actions,  are  a  long  time  of  being  destroyed,  by 
such  causes  as  would  instantaneously  kill  any  of  the  higher 
classes  :  We  may  remove  their  brain,  and  thus  materially  in- 
jure that  system,  in  which  the  specific  life  is  resident;  we 
may  cut  out  the  heart,  and  thus  destroy  the  circulation ;  or, 
We  may  prevent  the  purification  of  the  blood,  by  removing  or 
cutting  up  the  lungs ;  and  yet  the  animal,  under  any  or  all 
of  these  causes,  will  continue  to  live  for  many  hours,  some- 
times for  months. 

Where  the  life  is  of  the  highest  kind,  but  its  quantity  na- 
tuially  small,  and  the  action  required,  at  a  particular  time,  is 
very  little,  we  likewise  find  the  blood  impure.  This  we  see 
to  be  the  case  in  the  fetus  in  utero,  where  the  action  required 
is  very  trifling,  and  where  the  heat  produced*  (which  gene- 

*  As  the  foetus  is  placed  in  a  medium  as  warm  as  itself,  very  little  heat  is  ne- 
cessary to  be  produced,  in  order  to  keep  it  at  its  proper  standard. 
VOL.  I.  F 


42 

rally  bears  a  proportion  to  the  natural  purity  of  the  blood)  i» 
little. 

In  the  child  in  utero,  *"  the  blood  is  received  pure  from 
the  placenta  by  the  umbilical  vein,  and  is  conveyed  by  it  to 
the  navel  of  the  child.  Here  the  vein  enters,  and  passes  in- 
to the  liver,  dividing  in  it  into  many  branches,  which  ramify 
through  the  substance  of  that  gland,  whilst  the  continuation  of 
the  trunk  runs  forward,  and  terminates  in  one  of  the  branches 
of  the  vena  ports.  Thus,  we  find,  that  one  portion  of  the 
pure  blood  of  the  umbilical  vein  is  distributed  to  the  liver, 
whilst  the  rest  is  sent  directly  to  the  right  auricle  of  the 
heart ;  but,  previously,  it  is  mixed  in  its  passage  with  the 
impure  blood  in  the  vena  portae  and  vena  cava. 

"  There  is,  then,  by  this  contrivance,  a  mixed  blood  in  the 
right  side  of  the  heart,  which  is  purer  than  the  veinous  blood 
of  the  foetus,  but  much  less  arterial  than  the  blood  of  the  arte- 
ries after  birth ;  from  which  we  may  infer,  that  a  very  great 
change  takes  place  in  the  system  and  constitution  of  the  child 
after  delivery.  When  the  right  ventricle  contracts,  the  blood 
is  not  sent  through  the  lungs,  as  it  is  after  birth,  but  directly 
into  the  aorta,  at  its  curvature,  by  a  vessel  running  from  the 
pulmonary  artery  into  the  aorta.  By  thi3  construction,  we 
see  that  very  little  blood  should  enter  the  left  auricle ;  and, 
consequently,  that  the  whole  left  side  of  the  heart  should  be 
almost  empty.  But,  to  prevent  this  circumstance  from  hap- 
pening, we  find  an  opening  or  valve  in  the  septum,  betwixt 
the  auricles  of  the  heart,  which  permits  the  blood  to  flow  from 
the  right  to  the  left  side  directly,  and  then  the  whole  heart  is 
equally  filled.  It  is  for  preserving  the  heart  in  a  state  fit  for 
acting  after  birth,  that  we  have  both  a  foramen  ovale,  an^  a 
ductus  arteriosus.  Either  of  these,  individually,  would  have 
served  the  immediate  purposes  of  the  foetal  circulation  :  but, 

*  Anatomy  of  the  Gravid  Uterus,  p.  135.  et  seq. 


43 

by  thus  dividing  the  blood,  both  the  pulmonary  artery  and 
the  left  side  of  the  heart  are  kept  of  a  proper  size,  and  in  a  due 
state  of  action.* 

"  By  the  aorta,  this  semi-arterialized  blood  is  distributed 
to  the  body ;  but,  instead  of  the  whole  blood  in  the  descend- 
ing aorta  being  conveyed  to  the  viscera  and  inferior  extremi- 
ties, one  half  of  it  is  sent  directly  to  the  placenta ;  for  the  in- 
ternal iliac  arteries  turn  upward  to  the  navel,  through  which 
they  pass,  and  form  the  two  umbilical  arteries.  The  blood, 
therefore,  which  is  returned  to  the  placenta,  is  as  pure  as  that 
which  circulates  in  the  arteries  of  the  child,  and,  therefore, 
requires  a  less  change  to  convert  it  into  the  state  in  which  we 
find  it  in  the  umbilical  vein." 

If,  by  any  means,  the  blood  be  not  sufficiently  purified,  or, 
in  other  words,  if  it  do  not  possess,  to  a  sufficient  degree,  the 
properties  of  blood,  we  find,  that  the  powers  of  life  are  small, 
the  actions  of  the  whole  system  are  imperfectly  carried  on,  and 
the  individual  sinks  prematurely  into  the  grave.  When,  as 
has  been  already  mentioned,  the  adult  heart  remains  in  the 
same  state  with  that  of  the  fetus ;  when  the  pulmonary  arte- 
ry is  deficient ;  when  the  two  ventricles  communicate,  and 
the  aorta  arises  from  each ;  or,  when  the  lungs  themselves  are 
injured,  or  ill  formed,  then  the  most  distressing  symptoms 

*  "  The  use  of  the  sides  of  the  heart  is,  in  one  respect,  the  reverse  in  th  e 
foetus  of  what  it  is  after  birth*  In  the  foetus,  the  right  side  receives  the  purest 
blood,  whilst  the  left  receives  it  after  birth.  In  the  adult,  the  blood  which  hin  a 
r  state  fit  for  circulation,  is  collected  in  the  left  side ;  and  therefore,  the  great  artery 
of  the  body  arises  from  that  side.  On  this  account,  there  must  of  necessity  be  a 
communication  betwixt  the  aorta  and  the  right  side  of  the  foetus,  which  performs 
the  functions  of  the  left  side  of  the  adult  heart.  If  thi3  communication  does  not 
close  up  after  birth,  then  the  contents  of  the  right  side  continue  still  to  be  sent  in- 
to the  aorta.  But  as  the  quality  of  the  blood  of  the  right  side  is  now  materially 
different,  very  different  consequences  take  place  from  those  which  resulted  from 
the  same  mechanism  before  birth.  The  whole  blood  of  the  body  is  now  rendered 
impure,  the  purposes  of  circulation  are  only  half  performed,  and  the  unfortunate 
individual  drags  on  a  most  miserable  existence,  until  he  sinks  prematurely  info 
the  grave.  One  man,  from  whom  I  procured  a  preparation  of  this  kind  of  heait. 
iived  this  unhappy  life  for  forty  years." 


44 

lake  place  ;  distressing,  on  account  of  the  general  condition 
of  the  system,  but  still  more  painful,  from  the  local  affection 
produced  in  the  chest.     The  effect,  however,  of  the  want  of 
arterial  blood,  is  more  immediately  seen  in  cases  of  suspend- 
ed respiration.      In  hanging  or  drowning,  death  is  produced 
by  the  want  of  arterial  blood  ;  and  the  universal  method  of 
cure  has  been,  to  attempt  the  restoration  of  respiration,  al- 
though this  has  not  always  been  done  upon  the  true  principle. 
By  inflating  the  lungs,  respiration  is  often  restored,  but  it  also 
very  frequently  fails ;  because  the  mere  blowing  in  of  ail- 
neither  infallibly  excites  the  action  of  the  lungs,  nor  does  it, 
as  some  suppose,  change  the  blood;  for  this  change  is  an  ac- 
tion dependent  on  life,  and  cannot  be  imitated  by  the  chemist 
more  than  digestion.     The  alteration  of  the  blood  does  not 
depend,  as  many  imagine,  merely  on  the  presence  of  air ;  a 
peculiar  action  of  the  lungs,  or  their  vessels,  also  is  necessary. 
Food  and  air  are  to  be  considered  in  the  same  light,  both 
oniy  supplying  materials  for  the  system  to  act  on,  and  not 
themselves  acting  independently  of  the  animal.     When  in- 
flating the  lungs  does  not  very  speedily  restore  their  action, 
and  consequently  the  change  of  the  blood,  we  ought  to  trans- 
fuse arterial  blood  from  another  animal,  and  thus  reduce  the 
person  to  the  state  of  the  fcetus,  whose  blood  is  purified  by 
lungs  out  of  the  body. 

Of  the  Putee. 

I  have  said,  that  it  is  the  pure  or  arterial  blood  alone, 
which  is  valuable  to  the  system,  considered  as  a  whole,  and 
which  preserves  the  life,  and  yields  the  nourishment  of  the 
body.  This  is  sent  out  from  the  heart,  as  a  source  to  all  the 
different  parts  of  the  body,  by  regular  and  continued  contrac- 
tions of  the  heart  and  arteries,  and  is  returned  by  the  gentler 
action  of  the  veins.     These  contractions  depend  upon  the 


45 

living  principle,  connected  with  the  muscular  coats,  and  must 
be  influenced,  in  their  frequency  and  force,  by  the  state  or 
action  of  the  energy  of  the  system  in  general,  with  which  they 
sympathize  in  a  very  great  degree.* 

The  nervous  and  vascular  system  mutually  react  on  each 
other  ;  and,  therefore,  we  find  it  of  use,  in  disease,  to  attend 
to  the  state  of  the  vessels ;  because,  as  the  changes  induced 
on  them  are  some  of  them  of  a  mechanical  nature,  we  can 
more  easily  detect  them  than  the  nicer  alterations  in  the  ac- 
tion of  the  nervous  system,  were  we  to  confine  our  attention 
to  that  system  alone.  The  state  of  the  pulse,  then,  is  of  im- 
portance to  be  attended  to,  and  will  lead  us  to  ascertain  the 
presence,  and  sometimes  the  nature,  of  many  morbid  actions 
and  deviations. 

There  are  several  parts  of  the  vascular  system,  by  the  ac- 
tion of  which,  individually,  the  pulse  may  be  affected.  The 
heart,  and  great  artery,  the  smaller  arteries,  and  the  veins, 
all  influence  the  pulse ;  and  it  is  easy  to  ascertain  to  what 
degree  any  of  these  parts  operate. 

The  heart  is  the  origin  of  motion,  and  gives  to  the  pulse 
its  particular  feeling,  with  respect  to  motion,  such  as  regulari- 
ty, frequency,  slowness,  intermission,  fluttering,  Scc.-f 

*  Many  disputes  have  taken  place  concerning  the  action  of  the  heart ;  some 
referring  it  to  the  influence  of  the  nerves,  and  others  of  a  vis  insita.  If  I  nave  been 
right  in  my  position,  that  the  energy  is  universally  diffused  and  inherent  in  every 
part  of  the  nervous  system,  I  apprehend  that  the  arguments  in  support  of  the  ex- 
istence of  a  vis  insita  will  not  have  much  weight.  This  controversy  is  to  be  found 
stated  in  Haller's  Elementa  Physiologiae,  tome  I. 

Praxagorus  referred  it  to  a  vis  pulsitica,  or  peculiar  pulsatory  power  ;  others  to 
an  innate  heat,  which  rarified  the  blood,  whilst  the  air  cooled  it,  and  that  this  al- 
ternate operation  produced  pulsation ;  others  ascribed  it  to  fermentation. 

f  These  particular  states  of  the  pulse  always  depend  upon  the  heart.  In  all  in- 
creased actions  of  the  living  principle,  the  heart  is  affected,  and  contracts  oftener. 
In  all  instances  where  the  heart  is  affected  locally,  we  have  irregular  contractions 
or  intermissions,  as  we  find  to  be  the  case  in  spasmodic  affections  of  the  heart,  or 
its  great  vessels,  malconformation  of  the  heart,  diseases  of  the  aorta,  or  pulmona- 
system,  &c. 


46 

The  arteries  act  partly  by  their  elasticity,  and  partly  by 
their  muscular  power :  The  muscular  power  is  greatest  in 
the  smaller  arteries,  and  the  elasticity  in  the  larger  ;  the 
one  diminishing  as  the  other  increases  :  The  aorta  is  the 
most  elastic,  and  the  least  muscular  ;  and,  therefore,  its 
action  depends  chiefly  upon  that  of  the  heart,  to  which 
it  is  to  be  considered  as  an  appendage  :  The  action  of 
the  smaller  arteries,  again,  depends  much  upon  their  own 
contracting  power  ;  but  not  entirely  on  this  ;  for  the  elas- 
ticity of  their  coats  likewise  operates,  unless  the  artery  be 
very  small,  in  which  case  it  has  no  elasticity. 

There  are,  then,  in  the  arteries  of  the  arm,  for  instance, 
two  causes,  operating  in  producing  and  influencing  the  pulse  : 
First,  the  elasticity  of  the  artery;  and  this  cause  is  affected 
by  the  heart  :  Second,  the  muscular  contraction  of  their 
coats  ;  and  this  is  affected  only  by  their  own  condition,  inde- 
pendently of  the  force  of  the  heart.  As  the  heart,  then, 
gives  to  the  pulse  its  particular  feeling,  with  respect  to  motion, 
so  does  the  contraction  of  the  artery  give  to  it  the  particular 
feeling,  with  regard  to  size  and  quickness  of  contraction,  pro- 
ducing the  conditions  of  fulness,  smallness,  hardness,  soft- 
ness, &c. 

The  veins,  like  the  arteries,  act  partly  by  elasticity,  and 
partly  by  muscular  contraction ;  but  the  order  is  reversed  in 
them ;  for  the  greatest  veins  seem  to  have  most  muscular  ac- 
tion, whilst  the  small  ones  have  none,  or  almost  none. 

The  auricles  of  the  heart  belong  to  the  veinous  system, 
and  the  ventricles  to  the  arterial.  The  action  of  these  two 
parts  of  the  heart  is  alternate ;  and,  therefore,  the  action  of 
the  arteries  and  the  veins  is  likewise  alternate^  the  one  dila- 
ting, whilst  the  other  contracts.  In  health,  the  action  of  the 
veins  and  arteries  correspond  exactly,  and  a  regular  and  equa- 
ble circulation  of  the  blood  is  kept  up  ;  but,  in  disease,  they 
often  disagree,  at  least  in  the  commencement  of  the  diseased 


47 

action  ;  for  the  veins  are  less  irritable  than  the  arteries,  and 
are  longer  of  being  affected.* 

There  are,  then,  three  causes  which  affect  the  pulse  ;  and, 
by  attending  to  the  state  of  the  vascular  system,  we  may  as- 
certain the  proportion  in  which  these  operate,  in  any  particu- 
lar case :  First,  the  heart  and  aorta  ;  second,  the  branches 
of  the  aorta,  or  arteries  of  the  body  ;  third,  the  veinous  sys- 
tem. 

A  healthy  pulse  contracts  slowly  and  regularly,  and  the 
pulsations  do  not  exceed  about  seventy  in  the  minute :  We 
feel  the  artery  rising  softly  against  the  finger,  with  a  moderate 
degree  of  fulness.  In  disease,  the  pulse  becomes  either 
slower,  or  more  frequent,  full,  small,  hard,  weak,  or  strong.f 

*  External  heat,  and  many  other  agents,  induce  a  fulness  of  the  veins  for  a 
lime,  until  the  equilibrium  be  restored ;  and,  in  many  instances,  we  feel  the  acoi- 
inulation  of  blood  in  the  larger  and  internal  veins.  This  state  is  often  attended 
with  a  small  quick  pulse,  marking  a  contracted  state  of  the  arterial  system.  The 
skin  is  pale,  and  the  body  often  appears  to  be  shrunk,  as  we  see  in  the  commence- 
ment of  febrile  diseases. 

f  Practical  writers  have  admitted  of  an  almost  infinite  variety  of  pulses,  which 
.ire  now  believed  to  be,  in  a  great  degree,  imaginary,  and  therefore  are  overlook- 
ed. As  a  specimen  of  this,  I  shall  only  subjoin  an  extraet  from  the  Compend. 
Med.  of  De  Gorter,  who,  although  he  enumerates  many  distinctions,  which  we 
now  set  aside,  yet  has  not  given  the  third  part  of  what  many  others  mention. 

"  Si  cor  singulis  ictibus  majori  vi  contrahitur,  sanguis  celeriori  impetu  in  latera 
arteriarum  ruens  eas  dilatat  solito  magis,  qua?  dilatatio  digitis  percepta,  si  non 
multo  major  solito,  robustus  forluque  pulsus  dicitur  et  validus  ;  notans  cordis  vigo- 
rem,  et  copiam  sanguinis  singulis  ictibus  ejecti  :  in  morbis  bonum  praesagium,  nisi 
ob  cerebrum  compressum  at  in  apoplectici3,  et  contusione  cranii,  animi  deliquio 
scorbuticorum,  aut  ob  compressionem  notabilem  rami  arteriosi  hujusmodi  fiat 
pulsus. 

"  Vehemens  autem  pulsus,  digitos  veluti  removens  ab  arteria,  nee  quiescens  for- 
tiori digitorum  compressione,  ut  in  sanis  fieri  solet,  fortissimam  cordis  contractio- 
nem,  qua  spiritus  consumuntur,  et  motum  humorura  velocissimum  solida  destruen- 
tem  indicat.  Omnia  ergo  mala,  qua?  ex  his  fieri  solent,  praesagit,  et  videri  possuni 
in  aucta  circulatione.  In  morbis  acutis  inflammatoriis  et  erysipelatosis  ob- 
servatur. 

"  Quando  arteria  iastar  chorda?  tensa?  dura,  contra  digitos  attollitur,  Durvs 
dicitur  pulsus,  fortem  indicat  arteria?  impletionem,  cum  impedito  transitu  sangui- 
nis per  arteria?  extrema,  membranarum  internarum,  ut  pleura?,  et  meniDgum,  in- 
flfenimrvtioDi  comes.     Si  arterise  simul  constringuntur  magis,  est  durus  et  parvus  : 


48 

These  conditions  it  is  impossible  here  fully  to  describe.     I 
shall,  however,   keeping   the   general   observations   already 

alias  dtirub  et  magnus,  qui  melior :  prasagia  ex  inflammatione,  febreque  acuta 
ardf-nte  petenda. 

"  Si,  lmo,  cordis  consti  ictio  imbecillis  sit.  It  in  cerebri  coiupressione  phreniti- 
corum,  lethargicorum,  (Mirantiuiu,  tttanieorura,  soporosorum,  vol  ex  defectu 
spirituum  in  perinCi  mis,  morbid  vehementissimis  vires  corporis  superantibus.  '2>lo, 
Si  intercipiatur  fluxus  sanguinis  ad  cor,  ut  in  peripneumonia,  tubevculo  pulmonum, 
pleuritide  validissima,  sufficientem  pulmonis  explicalione  iuhibente  ;  vel  per  bepar 
eo  sc.  obstrueto,  aut  iuflammato,  vel  nimia  quanlitate  sanguinis  evacuala  extra 
corpus,  vel  collecta  in  cavis,  aut  vasis  dilatatis,  ut  in  hydropicis,  empyricis  :  hu- 
Bioris  nimia  evacuatione,  a  partu,  ruptioneque  vasorum  interna.  3iio,  Laxatus 
tonus  solidoruni  in  scorbuticis,  hystericis,  stomaclii  debilitate  laborantibus,  rachi- 
tide,  in  parte  paralytica,  leucophlegmaticis,  doloribus  flatulentis.  4to,  Inflainraa- 
tio  et  febris  ardens,  in  gangraenara  vel  sphacelum  abiens.  5to,  In  principio  inva- 
sionis  febrium,  pulsus  minori  vi  digitos  applicatos  percutit  et  attollit,  et  a  com- 
pressicne  eorum  paulo  mnjori  omnino  suffocari  potest ;  pulsus  hie  debilis  dicitur  a 
Medkis.  Quandoque  talis  videtur  fieri,  si  multa  pingucdiue  vel  tumore  aquo9o 
arteria  tecta  sit.  Talis  pulsus,  quia  arteria  minus  atlollitur,  humilis;  minus  per- 
cipi  potest,  obscurus;  arteriam  minus  dilatat,  cxilis,  gj-acilis,  exiguus,  parvus; 
minus  implet,  vacuus ;  tandem  in  summo  gradu  deficiens  et  deletus  dicitur,  quorum 
omnium  cognitio  et  praedictio  ex  his  clara. 

"  Alterum  quod  in  singulis  pulsibus  animadvertitur,  est  celeritas  et  tarditas. 
Celeritas  pulsuum,  quamvis  a  multis  Celeritas  cum  frequentia  confundatur,  omnino 
distinguenda  videtur,  intelligimus  enim  per  celeritatem,  si  ab  initio  diiatationis 
usque  ad  integram,  et  ab  ea  iterum  ad  quietem,  minori  temporis  spatio  peragitur, 
quam  in  sanis  pulsibus  fieri  debet;  quod  exploratione  digitorum  facile  percipien- 
dum.  Si  vires  deticiunt  cum  humorum  defectu,  atque  quodam  stimulo  irritante, 
cor  miniino  momento,  veluti  ictitans,  se  contrahens,  citissime  dilatat  arteriam 
brevi  tempore  subsidentem.  Ut  plurimum  in  cholera,  febre  et  temperamento  bili- 
oso,  atque  febre  erysipelatosa  obser/atur.  Dicitur  etiam  velox  et  ictitans  quan- 
doque. 

**  Huic  opposilus  est,  qui  vocatur  tardus  et  lenius,  in  visciditate  humorum  fre- 
quens  observatur,  ut  in  cachecticis,  scorbuticis,  leucophlegmaticis,  quod  ob  san- 
guinis lentorem  longius  tempus  insumatur,  antequam  integre  arteria  impleri  potest, 
et  cor  evacuari. 

"  Cordis  actio  in  pluribus  pulsibus  aut  frequentius,  aut  rarius  exercetur.  Qua; 
pulsationes  inter  unumquemque  ictum  brevius  spatium  temporis  relinquunt,  seu  si 
eodem  temporis  spatio  sapius  pulsant,  pulsus  dicitur  frequens,  a  quibusdam  celeris 
et  velox  dictus,  sed  perperam,  indicat  cordis  frequentiorcm  contractionem.  Quod 
fit,  lmo,  ab  irritatione  phlogistica,  ut  in  pleuritide,  phrenitide,  et  membranarum 
inflammatione,  quando  et  frequens  et  durus.  2do,  A  materia  acri  biliosa,  ut  in 
febribus  biliosis  et  erysipelatosis  et  frequens  et  celer.  3tio,  Defectu  virium,  ut  in 
principio  jnvasionis  febrium,  et  circa  statum,  quando  pessimus,  phthisiris,  perinfir- 
mis,  et  similibus  et  frequens  et  debilis;  si  vero,  Ito,  vires  adaugeantur,  ut  ex  usu 


49 

made  in  remembrance,  make  one  or  two  remarks  upon  some 
particular  states  of  the  pulse. 

Chalybis  in  chlorosi,  singulis  ictibus  corde  inajorem  copiam  sanguinis  ejiciente, 
pulsus  fit  frequentior  et  major. 

"  Huic  contrarius  est,  qui  longiori  intervallo  vibrat,  rarus  dictus, a multis etiam 
lentus  et  tardus,  quamvis  talis  ad  praecedens  genus  potius  pertineat.  Blandum  in- 
dicat  humorem,  hoc  si  ex  humorum  optabili  indole  provenit,  vasisque  apertb, 
magnitudine  compensatur  parvitas.  Verum  si  ob  visciditatem,  cerebrum  aut  cere- 
bellum obsessum  tenentem,  ut  in  pituitosis,  leucophlegmaticis,  catarrho  suffocative), 
syncope,  et  sopore,  atque  catalepsi  laborantibus,  fiat  rarus  et  parvus  aut  debilis, 
Eummum  periculum  imminet,  totum  cerebellum  obstructum  iri. 

"  Prater  cuncta  haec  pulsuum  genera,  qui  aequales  dicuntur,  aliud  est  quod  inae- 
quales  continet,  lmo,  in  unoquoque  ictu,  et  2do,  in  multis  simul.  Omnes  hi  pulsus 
nunquam  quidquam  boni  indicant,  non  semper  tamen  mortis  indicium  :  quibus- 
dam  enim  satis  familiares,  in  pulmonum  morbis  et  scorbuto  frequentes,  etin  quibus 
post  mortem  in  corde  polypus  fuit  inventus,  aut  pericardium  cordi  adnatum. 

"  Pulsus  singulis  ictibus  inaequalis,  tribus  ad  minimum  digitis  dignoscendus,  et 
qui  cum  aliqua  duritie  percipitur,  serratus  a  Medicis  dicitur.  Indicat  magnam 
cordis  constrictionem,  et  inaequalem  et  variis  in  partibus  arteria;  resistentiam. 
Mem  imo  pejora,  ut  pulsus  durus  prasagit. 

"  Si  satis  magna  sanguinis  quantitas  e  corde  pulsa  arteriam  non  nimis  resisten- 
tem  undas  ad  instar  successive  attollat,  undosus  vocatur  :  talis  observatur  in  hu- 
morum abundantia,  morbisque  acutiset  inflammatoriis,  si  crisin  per  sudorem  natu- 
ral moliatur,  et  quando  in  suppurationem  abeat;  in  morbis  autem  Chronicis  mate- 
riam  alicubi  harentem  in  sanguinem  receptam  esse  indicat. 

**  Si  cor  minori  vigore  contrahitur,  et  singulis  ictibus  insqualiter,  minor  quanti- 
tas e  corde  in  arterias  mittitur,  qua  arteria  successive  attollitur,  ac  si  vermis  sub 
digitis  serperet,  vermicular  is  pulsus  dicitur. 

"  Qui  minorem  adhuc  vim  cordis,  et  quantitatem  sanguinis  indicat,  simili  modo 
formicans  appellatur. 

"  Sed  vero  qui  versus  cor  magis :  et  versus  extrema  minus  dilatatur,  quod  cor 
non  valeat,  vel  deficiat  tantus  liquor,  ut  tota  arteria  impleatur,  (Auxgos ,  ex  simili- 
tudine  caudas  muris  a  veteribus  dicitur.  Qui  omnes  in  omnibus  morbis  periculosi 
sunt  habendi  pulsus. 

"  Qui  pulsus  plusquam  semel  videntur  attolli,  et  digitos  ferire,  Dicroti  vocantur 
si  simul  debiles  ;  verum  si  magis  robustus,  Caprizans  appellatur,  raro  nisi  inperin* 
firmis  observatur,  et  agone  mortis. 

"  Huic  quoque  referendus  vacillans  et  tremens,  inaequalem  et  inordinatam  arte- 
riarum  impletionem  indicans,  ex  denominatione  facile  definiendus;  vires  vitae 
fragiles  et  caducas  indicat. 

"  Inaequalium  alterum  genus  duas  continet  species,  lmo,  Intermiltentem,  qui 
una  alterave  vice  intercalatur  seu  deficit;  in  membranarum  inflammatione  gan«- 
granam  indicat,  in  acutis  pessimus,  in  poeris  vero  dormientibus,  plethoricis,  seni- 
bus,  praesertim  mulierculis  familiaris,  et  quibus  cor  pericardio  accretum  est. 

"  2do,  Mvx'gov,  qui  singulis  ictibus  minor  sentitur,  ut  in  moribundis,  quern  ite- 
rain  ulteriussine  necessitate  in  decurtatos,  reciptocos,  et  recurrentes  distmguunf-. 
VOI,.   I'.  fi 


50 

In  all  cases  where  the  pulse  becomes  suddenly  small,  we 
may  infer,  that  the  proper  balance  no  longer  exists  betwixt 
the  veinous  and  arterial  system,  but  that  the  one  is  acting 
more  than  the  other.  We  are  not  to  infer  from  this  state  of 
the  pulse,  any  thing  with  regard  to  the  quantity  of  blood  iu 
the  system;  nor  are  we  to  suppose,  that  the  blood  necessa- 
rily circulates  so  fast  through  the  lungs,  as  we  would  at  first 
suppose ;  because,  if  there  be  an  accumulation  in  the  veinous 
system,  the  same  quantity  will  not  pass  through  the  lungs,  at 
each  contraction  of -the  heart,  as  passed  in  health  ;  and, 
therefore,  more  will  not  necessarily  pass  in  a  given  time. 

We  are  not  always,  from  a  small  pulse,  to  infer,  that  the 
person  is  very  weak,  and  requires  cordials.  On  the  con- 
trary, whenever  this  stale  of  the  pulse  is  conjoined  with  a 
hardness,  we  may  pursue  a  contrary  plan,  and  detract  blood ; 
because  the  smallness  and  hardness  of  the  pulse  depends  upon 
the  complete  contraction  of  the  coats,  and  marks  an  action 
very  greatly  increased,  and  which  must  soon  kill,  if  it  be  not 
checked.  By  opening  a  vein,  we  render  the  pulse  slower, 
softer,  and  fuller,  as  we  see  in  abdominal  inflammation.  When- 
ever there  is  an  increased  contractile  power,  producing  hard- 


"  Mollis  fit  pulsus,  lmo,  si  sufficienter  non  impleatur,  defectu  sanguinis,  ut  in 
peripneumonia,  aliisque  pulinonum  morbis,  atque  hepatitide,  qui  tunc  semper 
malus.  2do,  Arteria  nimis  laxata,  ut  in  scorbuto,  leucophlegmatia,  quando  main*. 
3tio,  Minori  intluxu  spirituum,  ut  in  quiete  corporis  et  somno,  bonum  indicat ;  sed 
in  sopore,  cerebri  oppressionem.  4to,  Sedato  impetu  spirituum  in  fibras  motrices, 
cum  corporis  viribus  auctis,  et  pulsus  plenitudine,  bonus  in  febribus. 

"  Quantitas  humorum  in  corpore  contenta,  et  singulis  ictibus  e  corde  in  arteri- 
am  ejecta,  pulsum  magnum,  ■plenum,  altum,  latum,  manifestum  exhibet,  et  palpi, 
tntiouem.  Qui  boni,  nisi  fiant  a  nimia  copia  humorum,  vel  iinpedito  transfluxu 
spirituum  per  cerebrum,  ut  in  apoplexia,  lethargo,  phrenitide  :  vel  ab  obstruction* 
rami  notabilis  arteriffi. 

"  Sed  singulis  cordis  ictibus  minor  quantitas  in  arterias  derivata,  pulsum  par- 
vum,  vacuum,  gracilem,  obscurum,  debilet*,  et  etiam  dejicicntem,  facit;  hoc  si  fiat 
defectu  virium,  ut  in  sphacelo,  catarrho  suffocativo,  syncope,  iiifirniilato,  defectu 
sanguiuis,valde  malum:  sed  in  obesis,  arteria  ran  It  a  pinguedine  tec 
dicat." 


J 


51 

ness,  we  may  infer  the  existence  of  an  action,  in  some  part 
of  the  system,  of  an  inflammatory  nature,  and  will  often  be 
led  to  bleed,  from  this  mark  alone,  when,  from  other  cir- 
cumstances, we  would  deem  venesection  improper. 

In  general,  the  pulse  is  smaller  and  harder  in  inflammation, 
in  proportion  as  the  system  is  affected ;  and  hence  we  may, 
from  its  smallness,  judge  of  the  danger.  In  inflammation  of 
the  lungs,  we  have  seldom,  except  in  robust  and  plethoric 
people,  a  full  pulse ;  at  least,  if  the  inflammation  be  very 
acute.  In  inflammation  of  the  brain,  the  pulse  is  likewise 
hard,  and  seldom  full ;  though  the  state  of  the  pulse  is  not  so 
often  uniform  in  phienitis  ;  for  great  variations  take  place  in 
this  disease.  In  gastritis,  the  pulse  is  very  small,  and  quick. 
The  same  is  the  case  in  inflammation  of  the  small  intestines  ; 
but  it  is  rather  fuller,  when  the  great  intestines  alone  are  af- 
fected, and  inflammation  in  them  is  not  so  dangerous.  In 
cuticular  inflammation,  the  pulse  is  fuller,  but,  of  consequence, 
proportionally  slower. 

If  we  are  not  to  be  misled  by  a  small,  neither  are  we  to  be 
deceived  by  a  full  pulse ;  for  this  is  often  felt,  even  very  near 
dissolution.*  In  these  cases,  the  artery  is  contracting  very 
feebly,  and  is  approaching  to  the  nature  of  a  vein.  In  dan- 
gerous apoplexies,  the  pulse  is  likewise  often  full,  from  the 
diminished  power  of  the  artery. 

When  the  pulse  is  very  weak,  and  very  slow,  we  may 
infer,  that  the  general  action  of  the  system  is  much  diminish- 
ed, and  that  syncope,  or  death,  is  at  hand ;  for,  immediately 
before  death,  we  find  a  considerable  interval  betwixt  the 
feeble  contractions  of  the  heart. 

A  slow  pulse,  conjoined  with  local  pains,  shows,  that  no  in- 


*  In  acute  diseases,  it  is  a  very  bad  sign  to  find  the  pulse  full,  and  the  beat  very 
frequent ;  for  this  marks,  that  the  artery  is  unable  fully  to  contract:  We  feel  a  vi- 
bration, rather  than  a  contraction. 


52 

flammation  is  present,  but  that  the  sensation  proceeds  from  a 
different  cause,  often  a  convulsive  action  of  the  part. 

The  state  of  the  stomach,  and  abdominal  viscera,  influences 
the  circulation  greatly,  producing,  very  frequently,  a  remark- 
able slowness  of  the  pulse. 

Deviations,  in  the  function  of  circulation,  are  not  to  be  con- 
sidered as  diseases  in  themselves,  unless  they  depend  upon 
some  local  affection  of  the  organs  of  circulation  ;  and,  there- 
fore, we  are  not  always  to  direct  our  remedies  to  the  removal 
of  these  alterations  alone :  On  the  contrary,  we  more  fre- 
quently attend  to  them,  as  marks,  by  which  we  may  know 
what  kind  of  action  is  going  on.  If, .however,  the  diseased 
action  be  very  much  connected  with  the  circulation,  (as  in- 
flammation,) we  attempt  the  cure  by  remedies  directed  to  the 
vascular  system,  the  state  of  which  is  one  chief  and  dangerous 
symptom  of  the  disease. 

We  have  several  methods  of  affecting  the  vascular  system  ; 
such  as,  cold,  bleeding,  sweating,  stimulants,  &c. ;  and  these 
are  to  be  employed  with  two  views :  First,  to  restore  the  ba- 
lance between  the  veinous  and  arterial  system,  when  this  is 
destroyed ;  and,  for  this  purpose,  sweating  is  the  best  remedy 
which  we  can  employ :  Second,  to  obviate  some  particular 
conditions ;  such  as,  weakness,  hardness,  frequency,  &c. ;  and, 
for  this  purpose,  we  must  apply  the  appropriate  remedies ; 
such  as,  cordials,  bleeding,  &c. ;  or,  if  possible,  remove  the 
Cause. 

Of  the  Equilibrium  of  Action,  and  Sympathy. 

Having  proceeded  thus  far  in  the  account  of  the  living 
principle,  and  having  mentioned,  that  it  is  diffused,  in  an  equa- 
ble degree,  over  the  whole  body,*  I  may  next  observe,  that, 

*  Although  I  maintain,  that  the  vital  energy  is  diffused,  in  an  equable  manner, 
over  the  whole  body ;  that  is,  each  part  having  as  much,  in  proportion  to  its  ne- 


53 

m  a  state  of  health,  the  action  of  eacli  part  is  proportioned 
to  that  of  the  rest,  the  whole  acting  equally.  All  the  body 
is  sympathetically  connected  together,  and  dependent,  the 
one  part  upon  the  rest,  constituting  a  general  sympathy  :  But 
sometimes  we  find  particular  parts  more  intimately  depend- 
ent upon  each  other,  than  upon  the  rest  of  the  body,  consti- 
tuting a  particular  sympathy.  Action  cannot  be  greatly  in- 
creased, in  any  one  organ,  without  being  diminished  in  some 
other ;  but  certain  parts  are  more  apt  to  be  affected,  by  the 
derangement  of  particular  organs,  than  others ;  and  it  was 
the  observance  of  this  fact,  which  gave  foundation  to  the  old 
and  well-known  doctrine  of  sympathy,*  which  was  said  to 
proceed,  "  turn  ob  communionem  el  similitudinem  generis, 
turn  ob  viciniam."f 

It  may  be  thought,  that  this  position,  of  action  being  di- 
minished in  one  organ,  by  its  increase,  either  in  the  rest, 
or  in  some  other  part,  is  contradicted,  by  the  existence 
of  general  diseases,  or  actions,  affecting  the  whole  sys- 
tem :  But,  in  them,  we  find,  in  the  first  place,  that  there  is 
always  some  part  more  affected  than  the  rest.  This  local  af- 
fection is,  sometimes,  the  first  symptom,  and  affects  the  con- 
stitution, in  a  secondary  way,  either  by  the  irritation  which 

cessities,  as  another  ;  yet  I  do  not  mean  to  say,  that  each  part  possesses  absolutely 
the  same  quantity  :  The  reverse  is  the  case  ;  but  each  part  is,  in  health,  as  per- 
fectly supplied  with  it  a«  the  rest,  considered  with  regard  to  its  own  functions  and 
demand. 

*  Many  ridiculous  explanations  were  given,  of  the  consent  of  one  part  with 
another,  such  as,  similarity  of  intimate  structure,  anastomosis  of  blood-vessels, 
connexion  of  nerves,  &c.  The  theory  which  Hippocrates  had  of  sympathy,  is  to 
be  found  in  his  book,  De  Locis  in  Homine  :  "  Corpus  porro  ipsum  sibiipsi  idem 
ac  fimile  est,  et  ex  iisdem  compositum  est.  Similiter  autem  habet  et  parvas  et 
magnas  partei,  itemque  infernas  ac  supernas.  Et,  si  quis  minimam  corporis  par- 
tem acceptam  male  afficere  velit,  totum  corpus  affectionem  sentiet,  qualiscunque 
tandem  ea  fuerit ;  propterea  quicquid  tandem  minima  pars  pertulerit,  a  gentilita- 
tem  refert  ac  transfert,  unaqua?que  aff  suam,  sive  bonum  sive  malum  id  fuerit ;  et 
proptejea,  corpus  etdolet  et  laetatur  cum  minima  gente,  quia  in  minima  omnes  in- 
sunt  partes,  ethae  ad  gentiles  sibiipsis  singula  transferunt,  et  omnia  denunciant." 

f  Laurentii  Opera,  p. 323, 


54 

it  produces,  or  by  an  extension  of  the  specific  action-  At 
other  times,  the  local  affection  is  coeval  with  the  general  dis- 
ease, and  forms  a  part  of  the  direct  effect  of  the  exciting 
cause  which  produced  the  derangement.  In  the  first  case,  the 
general  disease  is  called  sympathetic  ;  in  the  second,  idio- 
pathic. We  observe,  in  the  second  place,  that,  as  there  is 
some  part  which  is  always  more  affected  than  the  rest,  so  also 
is  there  some  organ  which  has  its  action,  in  consequence  of 
this,  diminished  lower  than  that  of  the  rest  of  the  system, 
and,  most  commonly,  lower  than  its  natural  standard.  From 
the  extensive  sympathy  of  the  stomach,  with  almost  every 
part  of  the  body,  we  find,  that  this  most  frequently  suffers, 
and  has  its  action  diminished,  in  every  disease,  whether  ge- 
neral or  local,  provided  that  the  diseased  action  arises  to  any 
considerable  degree.  There  are  also  other  organs,  which 
may,  in  like  manner,  suffer,  from  their  association  or  con- 
nexion with  others  which  become  diseased,  as  will  be  imme- 
diately explained.  Thus,  for  instance,  we  see,  in  the  general 
disease  called  puerperal  fever,  that  the  action  of  the  breasts 
is  diminished,  by  the  increased  inflammatory  action  of  the 
uterus. 

In  consequence  of  this  balance  of  action,*  or  general  con- 
nexion of  the  system,  a  sudden  pain,  consequent  to  violent 
action  of  any  particular  part,  will  so  weaken  the  rest,  as  to 
produce  fainting,  and,  occasionally,  death.  But  this  depend- 
ence appears  more  evidently,  in  what  may  be  called  the  small- 
er systems  of  the  body,  or  those  parts  which  seem  to  be 

*  The  theory  of  a  balance,  of  any  kind,  existing  in  the  system,  was  first,  J  be- 
lieve, decidedly  pointed  out  by  the  late  Dr.  Irvine,  whose  chemical  knowledge  has 
deservedly  raised  his  name  higli  among  the  philosophers  of  Europe :  But  he  only 
imagined,  that  a  balance  of  sensibility  or  sensation  exists  in  the  body,  which  is  a 
doctrine  very  different  from  the  present,  which  supposes  a  balance  of  action.  The 
ancient  and  common  doctrine  of  sympathy, Vas  very  different  from  this,  which  I 
have  attempted  to  establish  ;  because  it  was  believed,  that  the  part  sympathizing 
became  affected  with  a  disease,  similar,  or  nearly  similar,  to  that  of  the  part  ori- 
ginally injured. 


55 

more  intimately  connected  with  each  other,  than  they  are 
with  the  general  system.  Of  this  kind  is  the  connexion  of 
the  breasts  with  the  uterus  of  the  female  ;  of  the  urethra 
with  the  testicles  of  the  male ;  of  the  stomach  with  the  liver  ; 
of  the  intestines  with  the  stomach,  and  of  this  again  with 
the  brain  ;  of  the  one  extremity  of  the  bone  with  the  other; 
of  the  body  of  the  muscle  with  its  insertion  ;  of  the  skin 
with  the  parts  below  it. 

Of  these  smaller  systems,  or  circles,  I  shall  treat  regularly ; 
but,  first,  it  may  be  proper  to  observe,  that  these  are  not 
only  intimately  connected  with  themselves,  but  also  with  the 
general  system,  an  universal  sympathy  being  thus  esta- 
blished. 

That  there  is  a  very  intimate  connexion  between  the 
breasts  and  uterus,  has  been  long  known,  but  it  has  not  been 
very  satisfactorily  explained.  Fallopius,  and  all  the  older 
authors,  declare  plainly,  that  the  sympathy  is  produced  by 
an  anastomosis  of  vessels ;  Bartholin  adding,  that  the  child 
being  born,  the  blood  no  longer  goes  to  the  uterus,  but  is  di- 
rected to  the  breasts,  and  changed  into  milk.  But  none  of 
ail  those  who  talk  of  this  derivation  assign  any  reasonable 
cause  which  may  produce  it. 

In  pregnancy,  and  at  the  menstrual  periods,  the  uterus  is 
active  ;  but,  when  the  child  is  delivered,  the  action  of  the 
uterus  subsides,  whilst  the  breasts,  in  their  turn,  become  ac- 
tive, and  secrete  milk.  If,  at  this  time,  we  should  again  pro- 
duce action  in  the  uterus,  we  diminish  that  of  the  breasts, 
.  and  destroy  the  secretion  of  milk,  as  is  well  illustrated  by 
the  case  of  inflammation  of  the  uterus,  which  is  incident  to 
lying-in  women.*  When  the  uterus,  at  the  cessation  of  the 
menses,  ceases  to  be  active,  or  to  secrete,  we  often  find,  that 


*  In  puerperal  fever,  when  the  uterus  becomes  inflamed,  the  secretion  of  miLt 
disappears,  until  the  action  of  the  uterus  ceases.  See  the  Anatomy  of  the  Gravid 
Uterus,  p.  73. 


the  breasts  have  an  action  excited  in  them,  becoming  slowly 
inflamed,  and  assuming  a  cancerous  disposition.  The  uterus 
and  breasts  seem  to  be  a  set  of  glands,  balancing  each  other, 
in  the  system,  one  only  being  naturally  active,  or  secreting 
properly,  at  a  time ;  and,  accordingly,  we  seldom,  if  ever, 
find,  that,  when  the  uterus  yields  the  menstrual  discharge, 
the  milk  is  secreted  in  perfection,  during  the  continuance  of 
that  discharge  ;  nor  do  we  ever  find  them  both  inflamed  at 
the  same  time. 

The  uterus  has  not  only  this  connexion  with  the  breasts, 
but  it  has  also  a  very  particular  sympathy  with  the  stomach, 
which  again  sympathises  with  the  brain ;  and  thus  we  see  how 
a  disorder  of  the  uterus  may  induce  an  extensive  series  of 
affections,  each  dependent  on  the  other. * 

The  uterus  has  been  known,  ever  since  the  foundation  of 
physic,  to  produce  very  extensive  disease  in  the  nervous 
system ;  and  it  is  amusing  to  hear  how  this  was  explained. 
The  disease  called  "  Suffocation  of  the  Uterus,"  with  many 
other  hysterical  ailments,  were  attributed  to  the  swelling  or 
choaking  up  of  the  uterus,  by  winds  and  vapours  generated 
from  the  retention  of  the  menses,  or  by  the  corruption  of  the 
semen,  and  putrefaction  of  the  bad  humours,  which  came  there 
to  be  discharged  ;  for  this  organ  was  considered  by  many  as 

a  common  cloaca. f      These  "  ventosities"  being  once  gene- 

• 

*  When  the  uterus  has  its  action  increased,  at  the  menstrual  period,  the  sto- 
mach is  often  much  affected,  and,  along  with  it,  the  brain,  and  whole  nervous  sys 
tern,  producing  hysteria.  There  is,  at  this  time,  every  symptom  of  weakened  sto- 
mach ;  such  as,  vomiting,  belching,  and,  not  unfrequently,  spasmodic  contractions.  * 
This  state  of  the  stomach  will,  in  its  turn,  affect  the  brain,  in  the  same  way  as  it 
does  after  a  debauch,  or  in  violent  dyspepsia  ;  that  is  to  say,  it  will  produce  head- 
ach  or  dizziness.  This  affection  of  the  head  is  not  the  immediate  consequence  o^ 
the  action  of  the  uterus,  but  depends  upon  the  disease  of  the  stomach,  induced  by 
the  uterus.  Thus  we  see  that  organs  may  come  to  suffer,  by  the  derangement  of  a 
particular  part,  although  they  do  not  directly  sympathise  with  that  part.  A  re- 
collection of  this  may  be  of  use  in  investigating  the  nature  of  some  complicated 
diseases. 

f  "  Cctte  partie  est  comme  un  cloacae  ou  sont  envoyez  tous  les  excrements  <tu 
corps."    Ambrose  Pare. 


57 

sated,  it  was  believed,  that  they  mounted  up  to  the  s'omach, 
the  liver,  and,  at  last,  to  the  brain.  The  cute  consis  ed  in 
expelling  these ;  and  one  of  the  remedies  which  was  employed 
for  this  purpose,  was  warm  aromatic  fumes,  conveyed,  by 
tubes,  to  the  os  uteri ;  for  there  was  no  safety,  they  imagin- 
ed, until  this  vile  stuff  was  discharged  ;  this  "  occuli  odour," 
as  Van  Helmont  calls  it. 

The  organs  of  generation  in  the  male,  form  likewise  a  li  :le 
system,  in  whi<  h  all  the  parts  exhibit  this  sympathy  wi.h  ea^h 
other.  They  likewise  give  us  a  very  good  instance  of  the 
association  of  action,  or  sympathy,  in  the  common  acceptation 
of  that  word. 

Sympathy  has  been  divided  into  the  contiguous,  where 
parts  become  affected  from  vicinity,  and  the  remote,  whee  a 
distant  part  becomes  affected.  It  will  be  more  conformable 
to  the  present  doctrine,  which  I  apprehend  to  be  true,  to  di- 
vide it  into,  first,  the  sympathy  of  equilibrium,  in  which  one 
part  is  weakened,  by  the  increased  action  of  another  ;  and, 
second  the  sympathy  of  association,  in  which  two  parts  act 
together,  at  the  same  time. 

The  sympathy  of  association  of  distant  parts  is  produced 
suddenly,  and  for  a  short  time  :  The  sympathy  of  equilib  ium 
is  produced  more  slowly,  and  continues  to  operate  for  a  much 
longer  time. 

It  is  curious  enough,  that  most,  or,  at  least,  many  of  those 
organs,  which  seem  to  be  connected  by  the  sympathy  of  equi- 
librium, exhibit  likewise  more  or  less  of  the  sympathy  of  as- 
sociation, when  under  the  circumstances  in  which  this  can 
lake  place. 

The  sympathy  of  association  may  be  divided  into  the  in* 
terrupted,  or  the  sympathia  consociationis  interrupta,  in  which 
distant  parts  are  affected,  whilst  sound  parts  intervene  be- 
twixt them;  and  the  spreading,  or  the  sympathia  consocia- 
tionis serpens,  in  which  the  action  spread*  inch  by  inch  witfc 

vol.  I.  H 


more  or  le^s  rapidity;  The  interrupted  sympathy  generally 
is  induced  quickly,  and,  in  many  cases,  does  not  last  long ; 
the  spreading  takes  place  more  gradually,  and  is,  in  every  in- 
stance, of  considerable  duration.  It  may  also  come  to  affect 
parts  which  were  formerly  influenced  by  the  interrupted 
sympathy,  and  may  overcome  the  natural  tendency  of  parti- 
cular parts  to  exhibit  the  sympathy  of  equilibrium.  The  in- 
terrupted sympathy  is  sometimes  the  forerunner  of  a  general 
action,  the  brain  or  stomach  sympathizing  before  any  other 
part  of  the  system. 

The  sympathy  of  equilibrium  is  seen  in  the  effects  of  in- 
flammation of  the  end  of  the  urelhra,  on  the  testicle,  which 
often  diminishes  its  action,  and  produces  a  very  disagreeable 
sensation  of  dulness ;  or,  if  this  inflammation  be  suddenly  di- 
minished, the  action  of  the  testicle  is  as  suddenly  increased, 
and  swelling  takes  place.  The  same  is  seen  in  the  connex- 
ion of  the  urethra  with  the  bladder  and  prostate  gland,  as 
will  be  more  fully  mentioned  in  the  dissertation  on  gonor- 
rhoea. These  parts,  likewise,  affect  the  stomach  greatly, 
increased  action  in  them  weakening  that  organ  much.*  This 
is  seen  in  the  effects  of  swelled  testicle,  on  excessive  venery, 
or  inflamed  bladder,  or  irritation  of  the  bladder,  from  a  stone; 
all  which  weaken  the  stomach,  and  produce  dyspepsia.  The 
same  remark  applies  to  the  kidney ;  vomiting  and  flatulence 
being  produced  by  nephritis. 

The  sympathy  of  association,  or  an  instance  of  sympathy, 
in  the  common  acceptation  of  the  word,  is  likewise  seen  in 
the  connexion  betwixt  the  glans  and  testicles,  in  coition ; 
but,  for  this  purpose,  the  action  in  the  glans  must  be  sudden, 
and  of  short  duration  ;  for,  if  continued  long,  weakness  of  the 

*  The  effects  of  excessive  venery,  in  producing  dyspepsia,  and,  consequently, 
gout,  is  very  well  known.  Unless  this  cause  be  removed,  it  is  impossible  for  pa- 
tients ever  to  recover  from  diseases  of  the  stomach.  Lord  Chesterfield  mention?, 
that  when  he  consulted  Booerhave,  that  celebrated  physician  added,  by  way  of  a- 
note to  lils  prescription,  "  Venus  rarius  colatur.''    Letter  cxxx- 


59 

testicles,  or  diminished  action,  is  induced.*  In  those  pans 
which  exhibit  this  natural  association  of  action,  if  the  action  of 
one  part  be  suddenly,  and  for  a  short  time,  increased,  the 
action  of  the  sympathising  part  will  likewise  be  increased,  as 
we  see,  in  the  instance  already  given,  of  coition,  and  likewise 
in  paroxysms  of  the  stone,  in  which  the  glans  penis,  after 
making  water,  becomes  very  painful :  But,  if  the  action  be 
more  slowly  induced,  and  continued  for  a  long  time,  then  this 
association  is  set  aside,  by  the  stronger  and  more  general  prin- 
ciple of  the  equilibrium  of  action,  and  the  sympathizing  part 
is  weakened.  Hence,  violent  inflammation  of  the  end  of  the 
urethra,  produces  a  weakness  and  irritability  of  the  bladder, 
dulness  of  the  testicles,  &c. 

There  is  also  an  evident  sympathy  of  equilibrium  betwixt 
the  stomach  and  lower  tract  of  in'.estines,  which  two  portions 
may  be  said,  in  general,  to  balance  each  oiher,  in  the  abdo- 
men. When  the  action  of  the  intestines  is  increased,  in  di- 
arrhoea, the  stomach  is  often  weakened,  and  the  patient  tor- 
mented with  nausea.  This  will  be  cured,  not  so  easily  by 
medicines  taken  into  the  stomach,  as  by  anodyne  clysters, 
which  will  abate  the  action  of  the  intestines.  When  the  in- 
testines are  inflamed,  as  in  strangulated  hernia,  vomiting  is  a 
never-failing  attendant :  When,  again,  the  stomach  is  inflamed, 
the  intestines  are  affected,  and  obstinate  costiveness  takes 
place.f  Even  in  hysterical  affections  of  the  stomach,  the 
intestines  are  often  deranged.  Injections  of  cold  water  fre- 
quently relieve  these  affections  of  the  stomach,  by  their  ac- 
tion on  the  intestines. 


*  It  is  on  this  principle,  that,  if  emission  does  not  take  place  quickly,  in  coitu, 
it  either  does  not  take  place  at  all,  or  with  difficulty.  If  the  state  of  the  glans  be 
such,  as  to  prevent  a  sudden  and  great  action,  iu  that  part,  no  emission  follows  . 
and  this  is  one  cause  of  impotence. 

f  It  might  be  thought,  that,  as  inflammation  of  the  intestines  produces  nausea 
or  vomiting,  so  gastritis  ought  to  be  attended,  uniformly,  with  looseness.  But  it 
■  is  to  be  remembered,  that  the  same  causes  produce  rery  different  effects  on  diff.r- 


60 

The  livfcr  and  stomach  are  also  connected  with  one  an- 
other. When  the  liver  is  inflamed,  or  has  its  action  increas- 
ed, the  stomach  is  weakened,  and  dyspeptic  symptoms  take 
place.  When  the  stomach  is  weakened,  as,  for  instance,  by 
intoxication,  then  the  action  of  the  liver  is  increased,  and  a 
gea.er  quantity  han  usual  of  bile  is  secreted.  The  same 
takes  place  in  warm  climates,  where  the  stomach  is  much  de- 
bilitated. If  the  liver  has  its  action  thus  frequently  increased, 
it  assumes  a  species  of  inflammation,  or  becomes,  as  it  is  called, 
schirrus.  This  is  exemplified  in  habitual  dram  drinkers, 
and  in  those  who  stay  long  in  warm  countries,  and  use 
freedoms  wiih  the  stomach.  The  liver  likewise  sympathizes 
with  ihe  brain ;  for  when  this  organ  is  injured,  and  its  action 
mu  h  impaired,  as  in  compression,  inflammation  and  suppu- 
ration have  been  often  known  to  take  place  in  the  liver. # 

Besides  this  connexion  of  the  stomach  with  the  liver,  it  is 
also  ve>.-y  intimately  dependent  on  the  brain,  being  weakened 
when  the  action  of  the  brain  is  increased,  as  we  see  in  inflam- 
mation of  that  organ.  The  brain,  again,  is  affected  with 
pain,  when  the  stomach  is  weakened  by  intoxication,  or  other 
causes  ;  and  this  pain  will  be  often  relieved  by  slowly  renew- 
ing ..he  action  of  the  stomach  by  such  stimuli  as  are  natural 
to  it,  such  as  small  quantities  of  soups  frequently  repeated. 
A  slight  increase  of  a-.tion  in  the  stomach,  at  least  if  not  of  a 
moibid  kind,  affects  the  brain  so  as  to  produce  sleep,  dimin- 
ishing its  action.  This  we  see  in  the  effects  of  a  full  meal, 
and  even  of  a  draught  of  warm  water.     The  stomach  like- 

ent  parts.  What  produces  mortal  sickness  in  one  part  of  the  alimentary  canal,  oc- 
caions  violent  pain  in  another;  and  the  sensation  and  consequence  of  diminished 
action  is  different  in  different  parts.  Dyspepsia  produces  squeamishness  in  the 
stomach  ;  but  the  same  cause,  affecting  the  intestines,  occasions  costiveness. 

Gastritis  may  be  accompanied  with  looseness;  but,  in  this  case,  there  must  be 
gome  irritating  cause  in  the  intestines. 

*  Mem.  de  L'Acad.  de  Cbirurg.  Tom.  III. 


CI 

wise  sympathises  with  the  throat,  squeamishness  and  anor- 
exia being  often  produced  by  inflammation  of  the  tonsils. 
This  inflammation  is  frequently  abated  by  restoring  or  in- 
creasing the  action  of  the  stomach.  Hence  the  throat,  in 
slight  inflammation,  is  frequently  easier  after  dinner :  Hence, 
likewise,  the  effect  of  emetics  in  cynanche. 

The  extremities  of  bones  and  muscles  also  sympathize  in 
the  same  manner.  When  one  end  of  a  bone  is  inflamed,  the 
action  of  the  other  is  lessened,  and  pain  is  produced  ;*  for  a 
painful  sensation  may  result  both  from  increased  and  dimin- 
ished action.  When  the  tendon  of  a  muscle  is  inflamed,  the 
body  of  that  muscle  often  is  pained  ;  and  vice  versa. 

Lastly,  the  external  skin  sympathizes  with  the  parts  be- 
low it.  If  it  be  inflamed,  as  in  erysipelas,  the  parts  immedi- 
ately beneath  are  weakened,  or  have  their  natural  action  di- 
minished. If  this  inflammation  affect  the  face  or  scalp,  then 
the  brain  is  injured,  and  head-ache,  stupor,  or  delirium  mite, 
supervenes.  If  it  attack  the  skin  of  the  abdomen,  then  the 
abdominal  viscera  are  affected,  and  we  have  vomiting  and 
purging,  or  obstinate  costiveness,  according  to  circumstances, 
as  explained  in  a  note  to  a  former  part  of  the  text.  This  is 
illustrated  by  the  disease  of  children,  which  is  called  by  the 
women  the  bowel  hive,  in  which  the  skin  is  inflamed,  as  they 
suppose,  from  some  morbid  matter  within. 

If  the  internal  parts  be  inflamed,  the  action  of  the  surface 
is  diminished  ;  and,  by  increasing  this  action,  we  can  lessen 
or  remove  the  disease  below,  as  we  see  daily  proved  by  the 
good  effects  of  blisters.  When  the  stomach,  intestines,  or 
kidney,  have  been  very  irritable,  I  have  known  a  sinapism 
act  like  a  charm  ;  and  in  the  deep-seated  inflammations  of  the 
breasts,  bowels,  or  joints,  we  know  of  no  better  remedy,  af- 
ter the  use  of  the  lancet,  than  blisters.     The  utility  of  issues, 

•:  To  give  only  one  example ;  in  morbus  coxarius,  the  knee  is  painful.- 


till 

in  diseases  of  the  lungs,  the  liver,  and  the  joints,  is  to  be  ex- 
plained on  the  same  principle.  In  these  cases,  we  find,  that 
issues  do  little  good  unless  they  be  somewhat  painful,  or  be  in 
the  state  of  healthy  ulcers.  An  indolent  flabby  sore,  how- 
ever large  the  discharge  (which  is  always  thin,  and  accompa- 
nied with  little  action,)  does  no  good,  but  only  adds  to  the 
misery  of  the  patient.  We  may,  however,  err  on  the  other 
hand,  by  making  the  issues  too  painful,  or  by  keeping  them  ac- 
tive too  long  ;  for,  after  they  have  removed  the  inflammatory 
disease  below,  they  will  still  operate  on  these  parts,  lessening 
their  action,  and  preventing  ihe  healing  process  from  going  on 
properly.  This  is  seen  in  cases  of  curvature  of  the  spine, 
where,  at  first,  the  inflammation  of  the  vertebra  is  diminished 
by  the  issues ;  but  if  they  be  kept  long  open  after  this  is  re- 
moved, they  do  harm.  We  often  see  the  patient  recover 
rapidly,  after  his  surgeon  has  healed  the  issue  in  despair, 
judging  that  it  could  do  no  farther  service,  but  only  increase 
tiie  weakness  of  his  patient. 

It  is  a  well  established  fact,  that  when  any  particular  action 
disappears  suddenly  from  a  part,  it  will  often  speedily  affect 
that  organ  which  sympathizes  most  with  the  part  which  was 
originally  diseased.  This  is  best  seen  in  the  inflammatory 
action,  which,  as  practical  writers  have  well  observed,  occa- 
sionally disappears  quickly  from  the  part  first  affected,  and 
then  shows  itself  in  some  other.*. 

From  the  united  testimony  of  all  these  facts,  I  may  cer- 
tainly maintain  the  doctrine  which  I  proposed  to  prove,  and 
introduce  it  into  pathological  reasonings.     In  the  whole  of  the 

*  In  the  cynanche  parotides,  the  testicle*  or  breasts  often  swell  in  proportion 
as  the  inflammation  leaves  the  parotid  gland.  There  are  many  instances  in  which 
the  increased  action  of  the  parotid  gland,  in  mercurial  salivation,  has  subsided 
suddenly,  and  affected  the  stomach  with  intolerable  irritability.  The  cessation  of 
the  inflammatory  action  of  the  urethra  in  gonorrhoea,  and  its  consequent  appear- 
ance in  the  testicles,  has  been  already  mentioned,  and  will  afterwards  be  mere 
fully  considered. 


t>3 

animal  economy,  we  discover  marks  of  the  wisdom  of  the  Cre- 
ator; but,  perhaps,  in  no  part  of  it  more  than  in  ihis,  of  the 
existence  of  the  sympathy  of  equilibrium  :  for,  if  a  large  part 
of  the  system  were  to  have  its  aclion  much  increased,  and  all 
the  oilier  parts  to  continue  acting,  in  the  same  proportionate 
degree  as  formerly,  the  whole  must  be  soon  exhausted,  (for 
increased  action  would  require,  for  its  support,  an  increased, 
quantity  of  energy.)  But,  upon  this  principle,  when  action  is 
much  increased  in  one  part,  it  is,  to  a  certain  degree,  dimin- 
ished in  some  other.  The  general  sum  or  degree  of  action  in 
the  body,  is  thus  less  than  it  otherwise  would  be,  and,  conse* 
quently,  the  system  suffers  less. 

Of  the  Actions  of  the  Nervous  Energy. 

Having  made  these  general  observations  upon  the  nervous 
system,  I  come  now  to  consider,  more  particularly,  its  differ- 
ent operations  or  actions.  These,  we  have  seen,  are  always 
induced  by  agents,  which  are  to  be  considered  as  external ; 
and  these  agents  are  called  stimuli.  The  action  or  operation 
which  is  produced,  depends,  first,  upon  the  nature  of  the  stim- 
ulus ;  and,  second,  upon  the  property  of  the  nerve.* 

Every  state  of  the  system  is  produced  by  an  operation  of 
the  nervous  energy ;  and  this  operation  is  called  an  action. 

Almost  every  substance  produces  some  change  upon  the 
system ;  and  these  changes  may  all  be  called  diseases,  if,  by 
this  term,  we  understand  a  condition  of  the  nervous  system, 
not  entirely  the  same  with  the  natural  state. 

*  There  are  many  nerves,  which  have,  ab  initio,  a  certain  function  or  property 
allotted  to  them,  which  h  excited  by  the  application  of  some  particular  or  specific 
stimulus.  But  after  this  peculiar  action  of  the  nerve  is  fully  established,  it  is  not 
always  necessary,  for  the  performance  of  these  actions,  that  the  specific  stimulus 
be  applied.  Light,  for  instance,  is  not  always  requisite,  for  the  sensation  or  action 
of  vision,  nor  air  for  hearing;  the  application  of  zinc  and  6ilver,  Ac.  being  capable 
of  producing  these 


m 

It  has  been  already  mentioned,  that  the  living  principle,  if 
aot  acted  on,  would  exh  bit  no  phenomena;  and  that,  although 
it  should  be  present  in  any  body,  we  should  still,  were  there 
no  aciion  produced,  conclude  that  body  to  be  dead.  The 
term  life,  in  common  language,-  is  applied,  not  to  the  living 
principle,  but  to  its  evident  operations,  or  actions.  These 
are  produced  by  certain  fixed  and  determinate  agents,  which 
act  constantly,  and  produce  what  is  called  the  healthy,  or 
natural  action,  (or,  in  common  language,  life.)  If  we  apply 
other  agents  than  those  which  are  namral,  we  modify,  or 
change  the  action ;  and,  in  proportion  as  the  new  action  dif- 
fers from  the  natural  one,  so  is  it  dangerous  to  the  system. 
These  actions  may  be  considered  as  different  varieties  of 
life,  if  we  use  this  term  in  its  vulgar  acceptation  ;  but  these 
varieties,  or,  at  least,  many  of  them,  not  being  fitted  to  our 
frame,  we  cannot  exist  long  with  them,  more  than  we  could, 
were  the  specific  life,  or  congeries  of  actions  of  a  quadruped, 
to  be  excited  in  us  by  any  magical  power. 

It  must  evidently  appear  difficult,  to  every  one  who  thinks* 
upon  the  subject,  to  say,  how  foreign  agents  operate  on  the 
living  principle  of  man,  or  how  a  small  particle  of  matter, 
taken  from  the  bowels  of  the  earth,  should  excite  a  dangerous 
and  mortal  action  of  the  vital  power  of  an  animal.  In  order, 
in  some  degree,  to  explain  this,  I  may  observe,  first,  that  no 
two  inert  bodies  can  act  on  each  other  ;  or,  in  other  words, 
that  matter  alone  cannot  act  on  matter,  unless  it  be  possessed 
of  some  active  power :  Neither  is  it  possible  for  an  inert  body 
to  act  on  one  possessed  of  this  enlivening  principle ;  for  the 
very  capability  of  producing  or  exciting  action,  implies  ac- 
tivity. Unless,  then,  both  agent  and  actor  possess  some  pro- 
perty different  from  mere  matter,  or  matter  truly  dead,  no 
change  can  be  produced.  Were  the  sun  to  lose  its  active 
power,  or  attraction,  it  could  no  longer  act  on  any  of  the 
planets  j  and*  were  any  of  the  planets  to  lose  their  power, 


05 

they  could  no  longer  be  acted  on  by  the  sun,  or  by  other 
planets.  If,  then,  it  be  admitted,  which  none  will  deny,  hat 
action  can  only  be  produced  in  a  body  which  is  alive,  and  by 
an  agent  possessed  of  an  active  principle,  it  will  follow,  that 
no  action  can  be  excited  in  an  animal,  except  by  means  of 
the  active  principle  of  the  agent  which  immediately  ex- 
cites it. 

I  shall,  secondly,  observe,  that,  as  the  vital  principle,  in 
animals  and  vegetables,  admits  of  modifications,  in  the  differ- 
ent individuals  with  which  it  is  connected,  so  also  does  the 
vital  or  active  principle  of  common  matter ;  and  it  is  these 
modifications  which  produce  the  essential  and  characteristic 
qualities  of  the  different  individuals,  or  different  kinds  of 
matter.  Chemistry  teaches  us,  that  there  are  not  many  kinds 
of  matter  radically  different;  and,  it  is  not  extravagant  to 
believe,  that,  were  science  improved,  or,  were  the  whole 
mystery  of  creation  unfolded,  we  might  find,  that  there  was 
only  one  radical  kind  of  matter,  which,  by  its  modification, 
yielded  different  products.  The  specific,  or  differential 
qualities  of  matter,  never  can  be  supposed  to  depend  upon 
any  cause,  inseparably  connected  with  mere  matter,  but  must 
depend  upon  the  operation  of  a  distinct  and  active  principle. 
We  may  mix  different  species  of  matter  together,  taken  fronv 
the  vegetable  or  mineral  kingdoms  ;  but  we  shall  not  make  a 
new  substance,  unless  the  active  principle  operate,  and  be- 
come modified,  converting  the  whole  into  a  new  individual. 

In  the  third  place,  I  remark,  that  a  modification  of  a  cause 
must  produce  an  alteration  in  the  effect. 

From  these  three  observations,  I  think  we  may  understand, 
first,  how  foreign  agents  are  capable  of  acting  on  the  body  ; 
and,  second,  why  different  agents  should  excite  different  ac- 
tions. 

I  may  further  observe,  that  it  is  only  the  attractive  princi- 
ple, or  life  of  matter,  which  operates  on  animal  Kfe,  exciting 

vol.  i.  i 


66 

it  to  action  ;  and  it  is  only  in  so  far  as  living  animals,  or  ve- 
getables, possess  properties  in  common  with  common  matter, 
that  they  can  excite  action  in  another  animal.  Hence,  when 
applied  to  the  body,  or  taken  into  the  stomach,  they  can  only 
excite  the  simple  actions  productive  of  the  sensation  of  feel- 
ing :  But,  after  the  animals,  or  vegetables,  die,  that  is  to  say, 
part  with  their  specific  life,  and  become  the  same  with  com- 
mon matter,  then  they  can  excite  peculiar  and  varied  actions ; 
then,  but  not  until  then,  can  they  be  changed,  and  rendered 
useful  as  food,  and  not  until  then,  do  they  ever  act  as  medi- 
cines. 

It  is  upon  the  principle  now  mentioned,  of  agents,  or  sti- 
muli, acting  only  on  the  body,  by  means  of  their  active  prin- 
ciple, that  we  are  to  explain  the  influence  of  these  larger 
masses  of  matter,  the  sun  and  moon,  upon  the  human  body. 
That  these  affect  the  body,  both  during  health  and  disease, 
has  been  so  fully  admitted,  by  so  many  attentive  physicians,* 
that  I  shall  consider  the  fact  as  established,  and  requiring  no 
farther  evidence  in  this  place. 

The  operation,  or  action,  of  the  system,  in  the  healthy 
state,  can  scarcely  be  described  ;  because  it  comprehends 
and  produces  every  circumstance  connected  with  health ; 
such  as,  sensibility,  muscular  contraction,  absorption,  nutri- 
tion, digestion,  and  all  the  other  functions  of  the  body. 
These  operations,  taken  collectively,  may  give  some  idea  of 
the  natural  or  healthy  action.  This  action  is  much  too  ex- 
tensive and  intricate  to  be  described,  or  defined ;  but  it  may 
be  understood,  by  observing  the  general  condition  of  a 
healthy  person. 

The  presence  of  this  action,  seems  also  to  be  requisite  for 
the  support  or  renewal  of  the  energy  which  produces  it ;  for, 
if  the  action  be  suspended,  or  totally  changed,  the  functions 

*  See  the  Works  of  Mead,  and,  more  lately,  the  Observations  of  Jackson, 
Salfour,  &e. 


67 

cease  ;  all  energy  is  lost,  and  death  takes  place.  Whilst  the 
action,  then,  depends  upon  the  power,  the  power  depends, 
for  its  continuance,  upon  the  action.*  Hence,  when  agents 
capable  of  exciting  an  action,  very  different  from  the  natural 
one,  are  applied,  we  may  readily  perceive,  how  weakness 
ought  to  be  the  consequence  :  On  the  contrary,  if  the  na- 
tural action  be  gradually  increased,  and  remain  unchanged, 
strength  will  be  produced.f  If,  however,  the  increase  of 
action  has  been  more  sudden,  and  to  a  greater  degree,  we 
find,  that  it  is  changed  in  its  nature,  and  is  no  longer  healthy, 
as  we  see  in  inflammation,  in  which  we  have  no  production 
of  strength,  but,  on  the  contrary,  an  expenditure  of  power. 
The  same  thing  happens,  when  particular  functions  are  in- 
creased in  their  action ;  such  as,  muscular  motion,  secre- 
tion, &c. 

The  nervous  system  has  its  energy  supported,  and  it* 
healthy  actions  excited,  by  arterial  blood,  which  may,  there- 
fore, be  called  a  natural  stimulus.  Heat,  air,  and  food,  are 
likewise  necessary  stimuli ;  but  these  all  act,  either  by  pre- 
paring the  blood,  or  imitating  its  operation.  Food  and  air 
give  to  the  blood  its  most  valuable  qualities  ;  and  heat,  appli- 

*  We  have  seen,  that  the  vitality  of  animals  is  received  from  common  matter, 
the  active  principle  of  which  is  gradually  changed,  and  rendered  more  perfect. 
It  is  from  the  life  of  the  blood,  that  all  energy  is  immediately  derived,  being,  in 
the  brain  and  nerves,  elevated  to  the  greatest  degree  of  perfection.  This  is,  un- 
doubtedly, the  effect  of  some  action  ;  for  it  is  not  done  by  any  innate  quality,  in- 
separably connected  with  vitality  itself;  otherwise,  we  might  find  it  raising  itself 
to  different  degrees  of  perfection,  in  the  very  lowest  orders  of  the  creation.  This 
action  is  not  seated  in  the  blood ;  otherwise,  we  should  find  the  life  more  perfect 
than  it  is,  in  the  blood ;  but  it  is  to  be  found  in  the  nervous  system,  which  perform-. 
all  the  actions  and  operations  of  the  body,  by  means  of  a  living  principle,  which, 
by  its  operation,  enables  it  to  renew  the  energy,  or  power.  The  nerves  alone  can- 
not do  this;  for  it  implies  an  active  operation,  which  they  cannot  perform  without 
life. 

t  If,  by  any  means,  the  energy  could  be  increased,  without  a  previous  increase 
of  action,  (which,  however,  is  impossible,)  we  should,  in  all  probability,  have  an 
immediate  increase  of  action.  Increase  of  energy,  and  increase  of  natural  action^ 
singly,  ought  to  produce  the  same  effect. 


62 

ed  externally,  only  co-operates  wiih  that  fluid,  which  pro-; 
duces  it  in  a  certain  quantity,  by  the  action  of  the  living 
system. 

When  other  agents  operate  on  the  system,  a  different  state 
from  that  produced  by  the  blood,  is  induced  in  the  body. 
Wine,  opium,  contagions,  mercury,  &c.  being  all  capable  of 
operating  on  the  system,  produce  an  action,  which,  of  neces- 
sity, must  be  different  from  the  natural  action,  inasmuch  as 
these  agenis  differ  from  the  natural  agent. 

New  agents  sometimes  appear  to  increase  the  natural  ac- 
tion, but  this,  it  is  evident,  they  never  can  do,  without  chang- 
ing or  modifying  it  in  some  respect  ;*  and,  therefore,  the 
opinion  that  they  produce  diseases,  consisting  entirely  of 
different  degrees  of  strength,  or  natural  action,  is  absurd. 
When  any  stimulus  has  been  applied  to  a  part,  so  as  to  pro- 
duce inflammation,  it  has  been  supposed  merely  to  increase 
the  vigour  of  the  part,  or,  in  the  language  of  Dr.  Brown,  to 
increase  its  s  henic  diathesis.     But  the  whole  series  of  symp- 

*  No  agent  can  excite  an  action  perfectly  similar  to  the  natural  one,  unless  it 
be  a  stimulus,  which  is  habitually  present,  such  as,  arterial  blood  and  heat.  Elec- 
tricity appears  to  increase  the  natural  action,  or  whatever  action  is  going  on  at 
the  time  of  its  application,  in  the  game  way  with  heat ;  but  we  cannot  call  elec- 
tricity a  new  agent;  for  it  certainly  operates,  habitually,  on  our  system,  although 
as  yet,  we  are  much  in  the  dark  respecting  it. 

Those  agents  which  are  natural  to  the  system,  are  found  to  increase  every  ac- 
tion which  is  going  on,  whether  healthy  or  diseased.  Hence,  blood  and  heat  will 
support,  not  only  the  natural  action,  but  also  any  other  which  has  been  induced. 
This  may  explain  to  us  the  u9e  of  heat  in  medicine,  and  may  also  inform  us, 
what  effects  we  are  to  expect  from  it.  In  warm  climates,  some  functions,  or  parts 
of  the  natural  action,  are  increased,  beyond  that  relation  which  ought  to  subsist 
betwixt  them  and  the  power,  and  weakness  is  produced.  All  the  secretory  ac- 
tions are  increased,  at  least,  such  as  are  not  incompatible  with  each  other ;  such 
ai  the  secretion  of  urine,  and  sweat,  which  cannot  both  be  increased  in  quantity 
at  the  same  time.  All  morbid  actions  are  increased ;  and  hence  the  danger  of  dis- 
eases in  warm  climates.  The  fever  is  violent,  and  runs  its  course  rapidly :  The 
action  in  ulcers  is  far  beyond  the  power,  and  the  destruction  is  great .-  The  con- 
tagion of  dysentery  acts  powerfully,  and  a  few  hours  decide  the  fate:  Blood,  liko 
heat,  increases  actions ;  and  hence  the  truth  of  the  old  observation,  "  That  ful!- 
Uooded  people  bear  disease  worse  than  the  spare." 


69 

foms,  In  that  disease,  show,  that  a  new  action  is  produced, 
diftering-^ery  much  from  the  natural  one,  both  in  its  progress 
and  consequences,  as  will  be  evidently  seen,  when  we  come 
afterwards  more  fully  to  examine  it.  The  vai  iolous  matter, 
again,  at  the  same  time  that  it  induces  the  inflammatory  ac- 
tion, modifies  it,  and,  in  a  very  striking  manner,  changes  its 
nature. 

Some  actions  appear  to  arise  without  any  evident  cause, 
or  to  be  repeated,  by  what  is  called  habit ;  but,  in  order  that 
this  may  take  place,  it  is  necessary,  first,  that  the  action  have 
been,  at  some  former  period,  strongly  excited,  or  long  con- 
tinued, or  frequently  repeated  :  Second,  that  either  some 
stimulus  be  applied,  which  has  been  frequently  applied  dur- 
ing the  former  continuance  of  the  action,  and  which  had  been 
accustomed  to  increase  it ;  or,  that  some  stimulus  be  applied, 
which,  in  its  effects,  bears  a  resemblance  to  some  part  of  the 
former  diseased  action,  which  is  thus  renewed.  Thus,  if  a 
person  has  once  had  an  ague,  he  is  apt  to  have  a  return  of  it, 
whenever  he  is  exposed  to  much  cold,  which  induces  a  state 
similar  to  the  former  cold  lit. 

In  all  morbid  actions,  we  have  three  periods  to  attend  to : 
First.  The  period  of  formation,  in  which  the  animal  is 
weakened,  by  the  diminution  of  the  natural  action,  or  func- 
tions, during  the  time  that  the  new  action  takes  to  form ;  for 
diseased  actions  never  take  place  suddenly,  (unless  the  excit- 
ing cause  be  very  powerful,  and  applied  only  to  a  particular 
part,  producing  local  disease,)  but  a  certain  time  is  required 
for  their  formation.  The  weakness  induced  in  this  way,  will 
be  observable  in  every  general  action,  and  even  in  those 
which,  when  fully  formed,  are  called  inflammatory.  The 
symptoms  which  take  place,  during  the  formation  of  an  action, 
are    lassitude,*    anorexia,   coldness,    head-ach,   and    thirst. 

*  This  proceeds,  in  a  great  measure,  from  the  diminution  of  the  action  of  the 
muscles.    In  many  instances,  this  diminution  of  natural  action  is  productive  of  a 


70 

These  always  occur,  ami  precede  aciions,  the  most  dissimilar 
one  to  the  other. 

Second.  The  period  in  which  the  action  exists  in  perfec- 
tion, and  fully  formed,  marked  by  the  peculiar  characters' 
of  the  action ;  such  as,  heat,  pain,  and  redness,  in  inflamma- 
tion ;  eruptions,  in  the  exanthemata? ;  peculiar  indescribable 
condition  in  typhus,  &c. 

Third.  The  termination.  All  new  actions  terminate  by  a 
secretion.  In  the  inflammatory  action,  we  have  either  a  se- 
cretion of  matter,  similar,  or'  nearly  similar,  to  the  natural 
substance  of  the  part,  producing  adhesion,  or  resolution,  as 
it  is  called ;  or  a  secretion  of  a  fluid,  called  pus,  serum,*  &c. 
In  many  other  actions,  however,  we  have  no  new  secretion 
formed,  but  only  an  augmentation,  and  perhaps,  slight  change, 
of  some  natural  and  accustomed  discharge ;  such  as,  sweat, 
mine,  or,  occasionally,  the  intestinal  mucus.  These  dis- 
charges, or  secretions,  are  sometimes  in  small  quantity ;  but, 
at  other  times,  they  are  more  considerable  and  evident.  By 
the  attentive  ancients,  they  were  called  critical,  as  they  were 
often  seen  to  occur  in  the  end  of  the  disease. 

Although  all  actions  terminate  in  a  secretion,  yet  it  does 
not  follow,  that,  whenever  the  secretion  appears,  disease  is 
to  end.  The  reverse  is  too  often  the  case ;  for,  in  many 
species  of  inflammation,  the  secretion  continues  permanent, 
unless  we  interrupt  it  by  art.  In  all  acute  diseases,  however, 
or  in  those  which  are  called  febrile,  the  secretion  does  not 
continue  permanent ;  and,  in  all  eruptive  actions  belonging 

very  painful  sensation,  which  is  felt  in  most  of  the  muscles,  and  which  causes  the 
patient  to  complain  of  pain  in  his  back  and  in  his  bones,  whilst  in  reality  it  is  the 
muscles  alone  which  are  pained.  Sometimes  this  diminution  of  natural  action  is 
productive  of  spasmodic  affections.  I  have  known  fevers  ushered  in  by  convulsions 
of  the  whole  muscles  of  the  body,  especially  of  the  spine,  and  these  continued 
during  the  period  of  formation. 

*  Pus  is  the  most  common  secretion,  terminating  inflammation  ;  but  it  may  also 
end  in  a  eecretion  of  thin  fluid,  like  serum,  producing  a  dropsy  of  the  affected  part. 
This  is  too  frequently  fatally  seen  in  the  head  and  chest. 


71 

to  this  class,  the  action  terminates,  whenever  this  secretion  Is 
completed ;  and  the  patient  is  then  subject  only  to  the  weak- 
ness which  the  action  may  have  induced,  and  to  the  effects 
which  the  eruption,  considered  as  simple  ulcers,  may  now 
produce.     This  is  seen  in  the  small-pox,  chicken-pox,  &c* 
Actions  are  only  known  and  distinguished  by  their  effects ; 
and  many  of  these  are  of  such  a  nature,  as  not  to  be  cognizable 
by  the  senses  ;  such  as,  the  peculiar  or  specific  state  of  the 
body,  in  typhus  fever,  small-pox,  &q.     The  precise  nature 
of  these  conditions,  can  neiiher  be  described  nor  understood ; 
because  they  cannot  be  brought  under  the  examination  of 
any  of  our  senses.     Some  have,  therefore,  denied  their  ex- 
istence ahogether,  or  have  not  perceived  it. 

In  almost  every  system  of  nosology,  they  have  been  en- 
tirely overlooked,  the  classification  being  founded  upon  such 
general  and  sensible  deviations,  as  occur  in  every  action,  over 
and  above  the  peculiar  condition ;  such  as,  affection  of  the 
circulation,  pains,  eruptions,  &c. 

Some  actions  are  confined  to  a  particular  part  of  the  body, 
whilst  others  affect  the  whole  system ;  and,  therefore,  nosolo- 
gists  have  uniformly  separated  these  diseases  from  each  other ; 
and,  at  first  sight,  we  might  conceive,  that  the  primary  and 
great  division  of  diseases  might  be  taken  from  this  source. 
But,  by  maturer  consideration,  we  shall  find  that  the  distinc- 
tion is  erroneous  ;  because  there  is  no  local  disease  whatever, 
which,  if  either  increased  in  degree,  or  continued  for  a  long 
time,  will  not  affect  the  constitution,  and  induce  a  general 
ailment.  On  the  other  hand,  there  is  no  action  which  affecte 
every  part  of  the  body  equally  ;  and,  therefore,  there  is  no 
general  disease  without  a  local  one ;  or,  in  other  words,  there 
is  always  some  part  of  the  body,  in  every  disease,  more  af- 

*  I  have  seen  the  measles  appear,  before  the  pustules  of  the  chicken-pox  were 
quite  gone,  which  could  not  have  happened,  unless  the  generaldisease^orpeculiar 
arctJOD,  had  disappeared,  when  the  secretion  took  place. 


72 

fected  than  the  rest.  In  the  exanthemata?,  the  skin  is  most 
affected ;  in  fevers,  strictly  so  called,  the  head  is  generally 
most  affec'ed,  although  sometimes  the  lungs  or  abdominal 
viscera  suffer  most.  Of  all  the  parts  of  the  body,  however, 
the  brain  generally  is  affected  in  the  greatest  degree,  unless 
the  disease  be  induced  by  some  cause  acting  locally  on  other 
parts  ;  but,  even  in  this  case,  if  the  disease  be  violent,  an  af- 
fection of  the  head  is  superadded  to  the  other  local  disease. 
This  is  exemplified,  in  the  case  of  those  who  die  after 
wounds  or  operations ;  in  which  event,  the  brain  is  common- 
ly found  turgid,  and  the  patient,  not  unfiequently,  is  affected 
with  coma  before  death.  In  certain  diseases,  we  observe  a 
series  of  aptitudes  of  the  different  parts  of  the  body  to  be 
affected,  as  will  af:ei  wards  be  particularly  illustrated  in  the 
venereal  disease.  In  all  actions,  the  least  sensible  parts 
suffer  latest.  This  we  see  in  the  case  of  the  bones,  tendons, 
and  cartilages. 

Actions  produce  different  symptoms,  according  as  they 
are  extended  over  the  body.  Such  as  affect  the  whole  sys- 
tem, produce  undefinable  uneasiness,  frequency  of  pulse, 
heat,  and  the  oiher  symptoms  of  what  is  called  fever.  But, 
when  action  appears  in  one  part  more  than  the  rest,  as  it  al- 
ways does,  that  part  is  affected  with  what  we  call  pain ;  and, 
if  the  action  be  still  more  increased  in  it,  we  have  a  species 
of  inflammation  induced.  This  is  illustrated  by  every  dis- 
ease which  we  know  of ;  for,  in  common  fever,  in  small-pox, 
and  every  specific  action,  we  find  inflammation  produced, 
whenever  action  becomes  much  concentrated  in  any  part.* 

*  Inflammation  in  a  part,  is  intimately  dependent  on  the  state  of  the  vessels. 
AU  actions,  which  produce  perceptible  disease,  affect  the  vessels,  making  thera 
contract  more  or  less  frequently,  and  more  or  less  strongly.  We  may,  therefore, 
gee  how  aDy  action,  when  greatly  mcraasod  in  a  part,  may  induce  inflam.*- 
motion. 


173 


Instead  of  adhering  to  the  more  established  modes  of  class- 
ing  diseases,  it  will  better  answer  the  present  purpose,  to  di- 
vide actions  into  the  six  following  classes.* 


CLASS  I. 
A.  Naturales. 

Alterations  in  the  performance  of  the  natural  action  of  a 
part  of  the  body,  or  of  the  whole  system,  but  not  to  such  a 
degree,  as  materially  to  change  its  nature,  or  render  it 
new.f 

Order  1.  Imperfecta. — A  diminution,  interruption,  or 
irregularity  of  the  performance  of  some  part,  or  the  whole  of 
the  natural  action.  J 

$*  This  arrangement  will,  it  is  true,  bring  together  diseases,  which  have  often 
heen  far  separated  ;  and  is  likewise  very  imperfect,  because  no  more  than  an  out- 
line of  the  classification  can  be  given  here.  The  minuter  subdivisions,  arising 
from  the  action  being  general  or  local,  and  from  the  function,  chiefly  impaired,  or 
other  circumstances,  cannot  be  noticed  in  this  sketch.  If  these  were  inserted, 
v  which  would  take  more  room  than  can  be  properly  spared  to  it,)  many  of  the 
Imperfections  and  apparent  inaccuracies  would  disappear  ;  but  no  system  of  noso- 
logy ever  has,  and,  until  our  knowledge  be  increased,  ever  can  be  free  from  fault. 
As  for  the  circumstance,  of  bringing  together  diseases  or  actions  formerly  separa- 
ted, I  have  uuly  to  remark,  that  the  dame  license  ought  to  be  allowed  for  uniting 
them,  as  for  separating  them,  both  proceeding  on  arbitrary  or  assumed  principles. 
In  this  arrangement,  the  actions  are  classed,  not  altogether  according  to  their 
cause,  but  chiefly  according  to  their  evident  effects  or  symptoms,  which  is  the 
most  useful  way  ;  the  object  of  medicine  as  yet  being  almost  totally  confined  to 
the  removal  of  symptoms.  To  comprehend  all  the  diseases  of  the  human  body, 
another  class,  consisting  of  actions  of  the  mind,  ought  to  be  added. 

f  We  shall  afterwards  find,  when  we  come  to  consider  inflammation,  that  if  the 
whole  natural  action  of  a  part  be  much  increased,  it  becomes  changed  in  its  na- 
ture and  effects :  But  the  present  class  comprehends  these  changes  only,  which 
take  place  to  such  a  degree,  as  not  to  alter  the  nature,  or  destroy  the  character- 
istic marks,  of  the  natural  action. 

\  This  order  may  be  subdivided,  according  as  it  affects  the  different  functions, 
&c.  and  comprehends  spasm,  epilepsy,  palpitation,  asthma,  dyspepsia,  cholic, 
rhlorosis,  torpor  from  cold,  &c. 

TOL.  I.  K 


74 

Order  2.  Accrescentes. — Some  part  of  the  natural 
action  morbidly  increased,  without  being  materially  changed 
in  its  nature.* 

Order  3.  Inequales. — A  loss  of  balance  betwixt  some 
part  of  the  natural  action.f 


CLASS  II. 
A.  Transposita. 

A  transposition  of  the  natural  action  of  some  part  of  the 
body  to.anoiber  part,  which,  in  health,  possesses  a  different 
action. 

Order  1.  Formantes. — A  transposition  of  the  action 
which  forms  the  part.  J  • 

Order  2.  Secernentes. — A  transposition  of  some  secre- 
tory act  ion.  || 

Order  3.  Sympathetic^e. — Actions  transferred,  by  sym- 
pathy, from  the  diseased  part  to  one  which  was  formerly 
healthy.** 

*  This  will  comprehend  cholera,  diarrhoea,  menorrhagia,  &c. 

j  This  comprehends  the  different  varieties  of  dropsy.  la  this  disease,  the  se- 
cretion and  absorption  do  not  balance  each  other. 

\  When  the  muscle-forming  action  is  lost  in  the  arteries,  and  membrane  is 
produced  in  its  place,  aneurism  is  the  consequence.  When  the  action  of  forming 
bone  is  transferred  to  the  heart,  a  very  serious  disease  takes  place.  When  the  ac 
tion  of  the  vessels  of  the  tunica  sclerotica  is  transferred  to  the  crystalline  lens,  ca- 
taract is  produced. 

!|  There  are  instances  recorded,  of  the  purulent  secretion  being  transferred  to 
some  part  which  formerly  was  sound.  There  are  many  cases,  where  the  menstrual 
discharge  has  come  from  different  parts  of  the  body. 

**  This  order  is  founded  on  the  doctrine  of  the  sympathy  of  equilibrium,  which 
haa  been  already  explained. 


75 

CLASS  III. 

A.  Similes. 

Actions  which,  when  analysed,  are  found  to  bear  a  resem- 
blance to  the  natural  action,  which  is  increased  to  such  a  de- 
gree, as  to  become  changed  in  its  nature.* 

Order  1.  Inflammat.e. — Actions  producing  heat,  red- 
ness, pain,  and  more  or  less  swelling,  in  some  particular  or- 
gan, often  attended  with  pyrexia.f 

Order  2.  Stimulantes. — A  general  increase  of  action, 
(without  such  a  local  affection  as  to  produce  true  inflamma- 
tion in  the  part,)  marked  by  frequency  of  pulse,  heat  of  the 
skin,  thirst,  and  pain  or  confusion  in  the  head.J 

Order  3.  San  guin  antes. — A  discharge  of  blood  from 
the  vessels  of  a  part,  without  any  artificial  wound,  accom- 
panied with  a  general  action  of  the  system. || 

Order  4.  Tonics. — Actions  consisting  in  an  increased 
contractile  power,  nearly,  though  not  entirely,  similar  to  the 
natural  action. *# 


*  The  change  of  the  nature  of  an  action,  from  a  change  of  its  degree,  will  be 
afterwards  illustrated,  in  the  dissertation  on  inflammation. 

f  This  order  comprehends  the  phlegmasia  of  nosologists. 

i  This  comprehends  the  slight  febrile  attack  called  ephemera ;  the  action  in- 
duced by  wine,  spirits,  hartshorn,  &c.  In  these  there  is  always  some  part  more 
affected  than  the  rest;  but  this  superior  affection  must  not  be  to  such  a  degree 
as  to  produce  inflammation ;  otherwise  the  action  will  belong  to  the  order  in- 
flammation. 

||  This  comprehends  the  order  hemorrhagia  of  nosologists.  The  subdivisions 
are  founded  on  the  part  affected.  Apoplexy  belongs  to  this  order,  being  produced 
by  a  hemorrhagic  action  in  the  brain. 

**  This  is  entirely  confined  to  the  effects  of  those  agents  called  medicines ;  such 
as,  alum,  galls,  bark,  bitters,  &c.  These  are  often  used  to  strengthen  the  body  ; 
because  they  excite  an  action  nearly  similar  to  the  natural  one  ;  and,  if  given 
gradually,  they  do  in  the  end  in  reality  increase  the  healthy  action,  by  having 
for  so  long  induced  one  in  an  increased  degree,  which  nearly  resembles  it. 


76 

Order  5.  Hecticje. — Frequent  pulse,  weakness,  sweats, 
and  purging,  heat  of  the  skin,  flushed  face,  thirst,  wasting  of 
the  body,  without  any  specific  action.* 

Order  6.  Mechanics. — General  action,  dependent 
chiefly  on  some  local  cause,  acting  mechanically-! 


CLASS  IV. 
A.   Dissimiles. 

Actions  very  dissimilar  to  the  natural  action,  and  which 
may  be  called  specific.  J 

Order  1.  Intermittentes. — Actions  which  alternately 
disappear  and  return,  or  remit  and  increase,  for  a  certain 
time.  1 1 

Order  2.  Typhoides. — Great  prostration  of  strength  ; 
pulse  frequent,  sometimes  full  at  first,  but  always  small,  after 
the  disease  has  continued  for  a  short  time  ;  pain  in  the  head, 
with  disturbance  of  the  mental  faculties  ;  urgent  thirst,  with 
foul  tongue.** 

Order  3.  Venenos.e. — Great  weakness,  often  attended 
with  eruptions,  or  other  local  affections,  produced  by  the  ap- 
plication of  what  are  called  poisons. f f 

*  The  different  species  of  phthisis,  attrophy,  fcc.  are  to  be  placed  here. 

f  Of  this  kind  is  jaundice,  proceeding  from  biliary  obstructions. 

X  These  are,  of  all  actions,  the  most  dangerous,  on  account  of  the  great  and 
rapid  weakness  which  most  of  them  induce.  Some  call  the  agents  productive  ol 
these,  sedatives ;  but  the  name  is  improper,  for  they  are  very  far  from  soothing. 
Agentes  dissimiles,  is,  from  the  poverty  of  language,  the  best  I  can  fix  on. 

||  Such  as  the  different  varieties  of  intermitting  fevers. 

**  Comprehends  typhus,  plague,  cynanche  maligna,  the  disease  produced  by  the 
application  of  putrid  matter  to  the  body,  &c. 

rf  The  bite  of  many  snakes,  the  effects  of  lead,  laurel,  &c. 


77 

CLASS   V. 

A.  Mixta'. 

Actions  which  are  of  a  mixed  nature,  resembling  in  part 
the  class  Similes,  but  having  also  some  peculiar  or  dissimilar 
action  united  to  this. 

Order  1.  Erupturje. — Actions  producing  numerous  in- 
flammations of  the  surface,  combined  with  a  specific  action, 
often  ending  in  ulceration.* 

Order  2.  Immupjd^. — Actions  consisting  in  specific  in- 
flammation, not  necessarily  confined  to  the  surface,  and  ge- 
nerally ending  in  ulceration.f 

Order  3.  Glandttlares. — Specific  actions,  producing  a 
change  in  the  quality  and  appearance  of  some  natural  secre- 
tion, which  is,  at  the  same  time,  generally  increased  in  quan- 
tity.J 

Order  4.  TJlcerantes. — Actions  consisting  in  simple 
ulceration  of  a  part,  without  any  specific  condition  being  con- 
joined.|| 

Order  5.  Connatje. — Morbid  actions  which  are  re- 
ceived at  conception.** 

Order  6.  Narcotics. — Actions  producing  frequency 
of  pulse,  stupor,  or  sleep,  with  a  disturbance  of  the  imagina- 
tion, and  an  inflammatory  or  hemorrhagic  action  of  the  brain, 
if  excited  to  a  sufficient  degree. ff 

*  Such  as  small-pox,  measles,  scarlatina,  cow-pox,  &c. 

f  Such  as  syphilis,  cancer,  elephantiasis,  frambcesia,  phagedena,  &c. 

X  Gonorrhoea  belongs  to  this  order. 

H  This  order  comprehends  ulcers,  succeeding  to  simple  inflammation,  which  may 
properly  enough  be  placed  under  the  class  Mixta,  as  the  granulating  action  is'  a 
natural  one,  and  the  purulent  action  an  unnatural  one. 

***  Such  as  scrophula. 

■■ff  Such  as  the  actions  of  opium,  hyocyamus,  belladona,  &c. 


7& 

Order  7.  Diminutje, — The  natural  action  chronically 
impaired,  and  some  peculiar  or  specific  action  conjoined.* 

Order  3.  Adaucta. — An  increase  of  some  function,  or 
part  of  the  natural  action,  conjoined  with  some  specific  con- 
dition.f 

Order  9.  Irritate. — Increased  and  specific  actions  of 
the  system,  productive  of  local  inflammation,  if  excited  to  a 
sufficient  degree.J 


CLASS   VI. 
A.  Meniales. 

Morbid  conditions,  seated  either  entirely  in  the  mind,  or 
operating  on  the  body,  through  the  influence  of  the  mind,  or 
on  the  mind,  through  the  influence  of  the  body. 

Order  1.  Idiopathic^. — Conditions  consisting  entirely 
in  some  mental  derangement,  without  any  considerable  altera- 
tions in  any  of  the  functions  of  the  animal. 

Order  2.  Corporeje. — Alterations  in  the  functions  of 
the  body,  in  consequence  of  some  morbid  operation  of  the 
mind. 

Order  3.  Symptomatica. — An  affection  of  the  mind, 
dependent  on  some  disease  of  the  body. 

*  Such  as  scorbutus. 

•j-  Pertussis,  diabetes,  &e. 

$  This  differs  both  from  the  order  Inflammatse  and  the  order  Stimulantes,  by 
having  a  specific  action  conjoined  with  the  general  or  local  increase.  It  compre 
tends  the  actions  of  mercury,  arsenic,  copper,  nitrous  acid,&c. 


79 

Every  new  or  morbid  action  has  naturally  a  certain  course 
which  it  is  inclined  to  run,  or  a  certain  series  of  symptoms  or 
effects  which  must  be  produced,  before  it  can  be  removed. 
When  this  course  is  accomplished,  and  the  action  has  become 
complete,  many  of  them  disappear,  and  the  natural  action  re- 
turns in  perfection.  This  is  illustrated  by  the  actions  of 
wine,  of  common  inflammation,  of  mercury,  and  of  typhus 
fever.  Others,  as,  for  instance,  intermitting  fevers,  having 
run  one  course,  begin  another,  exhibiting  a  series  of  alterna- 
tions betwixt  health  and  disease.  In  syphilis,  again,  and 
some  other  diseases,  we  find,  that  the  action,  when  completed 
and  made  perfect,  continues  in  that  state  without  diminishing 
or  disappearing. 

By  a  knowledge  of  the  facts  already  mentioned,  we  cure 
diseases,  or  remove  dangerous  actions.  Certain  actions,  we 
have  seen,  disappear  spontaneously,  after  having  run  their 
course :  These  we  may,  therefore,  either  altogether  neglect, 
or,  if  this  be  imprudent,  on  account  of  their  violence,  we 
may  attempt  to  make  them  run  their  course  more  speedily. 
When  a  part  becomes  inflamed,  we  find,  that  the  symptoms 
continue  increasing  for  a  time,  and  then  lessen,  leaving  the 
part  either  healthy,  or  in  possession  of  another  action,  called 
the  purulent.  In  this  disease,  then,  we  have  an  augmentation, 
an  acme,  and  a  decline.  When  we  attempt  to  diminish  this 
action,  we  make  that  period,  in  which  we  begin  our  treatment; 
the  acme,  and  the  subsequent  one  the  decline.  In  this  case, 
it  is  often,  though  not  always,  comparatively  speaking,  of 
little  consequence,  whether  we  endeavour,  by  art,  to  com- 
plete the  action  speedily,  or  allow  it  to  follow  its  course  more 
extensively  and  tediously.  But,  in  the  typhus  fever,  the 
danger  is  always  increasing,  in  proportion  to  the  duration  of 
the  action  ;  and,  therefore,  we  ought,  if  possible,  to  complete 
it  speedily.     This  we  endeavour  to  do,  in  the  very  begin- 


80 

aing,  by  an  emetic,  which,  inducing  the  hot  and  sweating 
stages,  often  terminates  the  action. 

There  are  other  actions,  however,  which,  we  have  seen, 
have  no  tendency  to  disappear,  after  all  the  stages  are  gone 
through.  Of  this  kind,  amongst  many  others,  are  intermit- 
tent fever  and  syphilis.  In  these  diseases,  then,  we  must 
unavoidably  follow,  in  every  instance,  that  course,  which,  in 
inflammation,  we  may  or  may  not  pursue,  as  circumstances 
direct ;  namely,  diminish  the  morbid  action,  by  artificially  re- 
storing the  natural  one.  In  inflammation  of  strong  parts,  we 
might,  by  induction,  discover  the  method  of  restoring  health; 
for,  if  the  disease  consists  in  the  natural  action,  increased  to 
such  a  morbid  degree  as  to  change  its  nature,  it  is  plain,  that 
whatever  would,  in  health,  diminish  the  natural  action,  must 
here  be  of  service.  But,  in  the  cure  of  the  diseased  actions 
at  present  under  consideration,  we  can  derive  no  such  assist- 
ance from  reasoning  or  judgment,  because  we  are  not  so  well 
acquainted  with  the  nature  of  these  actions.  We  have,  ac- 
cordingly, been  altogether  indebted  to  empyrism  for  a  cure  ; 
but  now,  that  the  remedies  are  discovered,  we  can  ascertain 
the  principle  on  which  we  proceed.  In  these  diseases,  it  is 
impossible  to  restore  directly  the  natural  action  ;  because  the 
morbid  one  will  not  yield  to  it.  We  are,  therefore,  obliged 
to  destroy  the  diseased  action,  by  inducing  another  which  is 
able  to  displaee  it,  in  the  same  way  as  it  had  removed  the 
natural  one.  But  this  is  not  all  which  must  be  done  ;  for  we 
should  still  have  only  exchanged  one  disease  for  another, 
unless  we  had  been  careful  to  remove  the  first  and  obstinate 
diseased  action,  by  another  which  would  disappear,  after 
having  run  its  course,  and  allow  the  natural  one  again  to  ap- 
pear.*    To  apply  this  to  syphilis ;  it  may  be  observed,  that 

*  Jn  the  cure  of  diseases,  we  ought  not  only  to  attempt  removing  the  mor- 
feid  action,  by  inducing  such  another  general  condition  as  shall  answer  our  in- 
tention ;  but  also,  to  attend  to  the  removal  of  particular  symptoms  of  the  ac- 


ai 

the  nuarcurial  action  is  as  dissimilar  to  the  venereal  action,  as 
this  last  was  to  the  natural  one  ;  and,  therefore,  will  remove 
it  in  the  same  way,  and  exactly  on  the  same  principle  on 
which  the  venereal  action  had  taken  place  of  the  natural  one. 
This  being  done,  the  patient  is  cured  of  one  disease,  but  still 
labours  under  another,  namely,  the  mercurial  action.  When 
this  subsides,  he  is  well.  In  the  same  way,  bark,  arsenic, 
&c.  cure  agues. 

Unfortunately,  we  are  not  able  practically  to  apply  this 
doctrine  to  the  cure  of  many  diseases ;  but  this  inability  re- 
sults not  from  any  fault  of  the  doctrine  itself,  but  from  our 
own  ignorance  of  the  nature  of  various  actions,  which  pre- 
vents our  opposing  one  to  another  with  success.*  Antimo- 
ny has,  by  some,  been  proposed  for  removing  the  typhus  ac- 
tion, cicuta  for  removing  the  cancerous  disease,  whilst  the 
scrophula  has  been  promised  to  be  cured  by  the  muriated 
barytes,  and  the  small-pox  to  be  prevented  by  mercury. 
But  melancholy  experience  testifies  the  inefticacy  of  all  these 
proposals,  and  the  impossibility,  as  yet,  of  inducing  an  action 
capable  of  displacing  these  terrible  diseases. 

tion,  which  will  much  co-operate  with  our  general  plan.  In  those  actions, 
which  we  cannot  yet  cure  by  general  remedies,  we  are  confined  entirely  to 
this  removal  of  symptoms ;  and  a  proper  interference,  in  this  respect,  by  the 
application  of  such  remedies  as  shall  do  so,  without,  at  the  same  time,  tending 
to  increase  the  morbid  action,  considered  as  a  whole,  requires  the  greatest  dis- 
cernment of  the  physician.  In  fevers,  and  many  other  diseases,  people  are 
.much  weakened;  but  he  who  should,  from  the  beginning,  attempt  to  obviate 
this  by  wine,  would  find  the  general  action  much  increased  by  it,  and  his 
patient  rendered  worse. 

*  It  is  a  great  loss  to  medicine,  that  distinctions  have  carefully  been  made 
betwixt  what  are  called  diseases,  and  what  are  called  remedies.  Do  not  the 
agents  called  medicines,  and  those  which  produce  what  we  call  disease,  act 
all  on  the  same  principle  ?  Do  not  both  .-lasses  produce  diseases,  or  unnatu» 
ral  actions  ?  Might  we  not  sometimes  derive  benefit  from  the  actions  which 
we  call  diseases,  and  which,  in  this  case,  we  should  find  to  be  useful  remedies  ? 
This  has,  in  part,  been  admitted  by  many,  who  have  wrote  on  the  good  effects 
<»f  fevers  in  removing  other  diseases.  It  would,  however,  be  requisite,  that  we 
should  never  induce  a  more  dangerous  action,  in  ordet  ir  destroy  one  les?. 
V"OL.    I.  L 


82 

To  conclude  these  observations,  I  may  remark,  that,  al- 
though we  may  remove  one  action  by  inducing  another,  yet 
this  cannot  be  done,  un'iil  the  first  has  gone  through  all  the 
essential  stages  to  become  perfect.  Thus,  mercury  will  not 
cure  the  venereal  action,  until  inflammation,  which  is  essen- 
tial to  the  perfection  of  that  action,  has  taken  place.  The 
typhus  action  cannot  be  removed,  without  sweating,  or  mois- 
ture on  the  surface,  or  some  other  secretion.  The  natural 
action,  being  always  at  its  acme,  or  always  complete,  can  be 
removed  at  any  time  ;  and  the  same  may  be  said  of  the  in- 
flammatory. 

Of  the  different  Systems  of  Pathology. 

From  what  has  l>een  said,  it  may  appear,  that  we  are  to 
ascribe  both  the  health  and  disease  of  an  animal  to  the  ope- 
ration of  the  living  principle.  Until  within  these  few  years, 
however,  physicians  have  been  too  apt  to  imagine,  that  the 
diseases  of  man  were  similar  to  the  changes  induced  on  com- 
mon matter,  referring  them  entirely  eilher  to  an  augmentation 
or  diminution  of  his  fluids,  or  to  a  depravation  of  the  hu- 
mours. 

The  different  fluids  of  the  body  were  all  divided,  by  the 
ancients,  into  the  natural,  the  secondary,  and  the  unnatural 
humours.  The  natural  humours,  they  said,  were  four  in 
number  :  First,  the  phlegm,  or  pituita,  which  was  prepared 
from  cold  and  crude  aliment,  and  in  greatest  abundance  in 
old  age,  or  the  winter  season,  when  the  low  degree  of  heat 
favoured  its  production.  This  pituila  was  formed  in  the 
brain,  from  whence  it  descended,  to  lubricate  the  joints,  and 
dilute  the  blood  :  It  ftom  ished  and  supported  the  brain, 
and  the  cold  parts  of  the  body.*     Second,  the  choler,  or 

•  The  different  parts  of  the  body  were  supposed  to  be  either  hot  or  cold,  dry 


83 

yellow  bile, ..which  was  prepared  in  the  liver:  It  was  of  a 
very  hot  and  fiery  nature  ;  and,  therefore,  nourished  the  hot 
parts,  at  the  same  time  that  it  corrected  the  pituita,  and 
purged  the  intestines.  Third,  the  atra  bilis,  or  melancholic 
humour  :  This  was  prepared  in  the  spleen,  which  it  nourish- 
ed, as  well  as  the  drier  parts  of  the  body  ;  it  likewise  pro- 
moted appetite.  Fourth,  the  blood,  which  was  prepaied  in 
the  liver,  from  whence  it  was  sent  to  all  the  different  parts 
of  the  body,  going  out  by  day  to  the  extremities,  and  return- 
ing by  night  to  the  more  noble  parts.* 

These  humours  were  supposed  to  operate  more  at  one 
time  than  another,  or  to  reign  alternately ;  and,  upon  this 
conjecture,  they  explained,  why  certain  diseases  were  worse 
at  particular  hours ;  the  humour  which  produced  them  being 
then  in  its  greatest  force.  The  blood  reigned  from  three 
o'clock  in  the  morning  until  nine ;  the  choler,  from  nine  in 
the  morning  until  three  o'clock  in  the  afternoon ;  the  black 
bile,  from  this  hour  until  nine  in  the  evening  ;  and  the  pitni- 
ta,  from  nine  until  the  blood  began  again  its  reign. 

The  secondary  humours  were  the  invention  of  the  Arabi- 
ans, and  were  said  by  them  to  be  the  different  steps  toward 
nourishment  :  They  were  furnished  by  the  blood,  when  it 
came  to  the  part  which  was  to  be  nourished. 


ov  humid.    The  brain  was  one  of  the  cold  parts,  and  was  supposed,  by  Aristotle, 
to  moderate  the  heat  of  the  heart.     Aristot.  de  Part.  Anim.  cap.  vii.  lib.  2. 

*  "  Mundus  quatuor  ex  elementis  consistit,  igne,  aere,  terra,  et  aqua :  calido 
videlicet  huinido,  frigido,  et  sicco.  lisdemex  elementis  quatuor  totidemque  humo- 
ribustt  homo  consistit ;  sanguine  scilicet,  pituita,  flava,  et  atra  bili.  Et  sanguis 
quidem  aeri,  pituita  aqua?,  flava  autem  bilis  igni,  atra  veroterrae  simulatur.  San- 
guis enim  gu;tu  dulcis  est ;  pituita,  salsa  ;  flava  bilis,  amara ;  atra  vero  ascetosa, 
et  flavescens.  Sanguinis  autem  locus,  et  spiritus  in  corde  est.  A  dextris  quidem 
ejus  sanguis,  a  sinistris  vero,  spiritus  consistit.  Flava?  bilis  in  jecinore ;  atrae  in. 
lierte  ;  pituita  quidem  in  cerebro,  locus.  Sanguis  autem  calidus  et  humidus;  pitui- 
ta frigida  et  humida  j  Aava  bills,  calida  et  sicca  ;  atra  vero  sicca  et  frigida." 

Hippocr.  dt  Horn,  Struct  ad  Perdicam,  Sec. 


84 

The  unnatural  humours  were  those  which  were  perverted 
and  diseased ;  and  then,  whatever  might  have  been  their 
former  quality,  they  become  hot.  The  blood*  and  melan- 
choly corrupted  only  in  the  veins  ;  the  other  two  humours 
corrupted  out  of  the  vessels. 

These  humours  were  supposed  to  possess  different  quali- 
ties, which  they  communicated  to  the  body,  and  upon  which 
depended  the  peculiar  properties  of  the  body,  considered 
either  as  a  whole  or  a  part.  These  states  were  called  con- 
ditions, or  temperaments,  or  constitutions  ;  terms  which  are 
still  retained,  and  meant  to  express  the  peculiar  habit  of 
body  ;  as,  strong,  weak,  scrophulous,  &c.f 

The  peripatetics,  by  the  term  temperament,  or  temperies, 
meant  the  condition  of  the  body,  with  regard  to  the  propor- 
tion of  elements  which  it  contained.  The  blood  was  said  to 
be  hot  and  moist ;  melancholy,  cold  and  dry  ;  choler,  hot 
and  dry ;  phlegm,  cold  and  moist.  According,  then,  as 
these  humours  preponderated,  the  body  was  said  to  possess  a 
cold,  hot,  dry,  or  moist  quality,  condition,  or  temperament : 
And  as  these  states  were  produced  by  the  presence  of  the 
humours,  physicians  at  last  came  to  name  the  temperament, 
from  the  humour  which  produced  it,  instead  of  the  quality 
which  it  imparted.  Thus,  we  had  the  sanguineous,  choleric 
(or  bilious,)  melancholic  (or  atrabilian,)  and  phlegmatic  (or 
pituitous)  temperaments,  with  many  admixtures  of  each 
other,  as,  for  instance,  the  sanguineo-choleric,  &c. 

When  the  doctrines  of  the  ancients  came  to  be  more  fully 
commented  on,  the  temperaments  were  more  minutely  sub- 


*  When  the  blood  corrupted  in  its  thicker  part,  it  turned  into  melancholy ;  but 
when  its  thinner  part  was  in  fault,  then  it  became  choler. 

t  Instead  of  adhering  to  the  old  names,  which  depended  upon  the  ancient  theo- 
ries of  physic,  practitioners  have  substituted  a  variety  of  new  ones,  corresponding 
to  their  own  opinions ;  such  as,  phlogistic,  caheetic,  sthenic,,  asthenic,  irritabje. , 


85 

divided  and  explained.  The  temperies  bona  consisted,  in  a 
due  proportion  of  all  the  qualities  capable  of  being  possessed 
by  a  body ;  such  as,  heat,  cold,  dryness,  moisture,  density, 
rarity,  hardness,  softness,  viscidity,  volatility,  &c.  The  tem- 
peries was  called  moderate,  when  the  qualities  were  of  a  mo- 
derate degree  ;  immoderate,  when  they  went  beyond  mode- 
ration. It  was  called  total,  when  it  affected  the  whole  body ; 
and  this,  again,  was  divided  into  the  sanguineous,  melancho- 
lic, bilious,  and  pituitous,  according  as  these  humours  pre- 
dominated. It  was  called  partial,  when  the  condition  of  dif- 
ferent parts  was  considered  individually.  Thus,  the  brain 
was  cold  and  moist ;  the  heart,  hot  and  moist  ;  the  bone, 
dry  and  cold  ;  and  a  regular  gradation,  or  series  of  changes, 
was  established  betwixt  these,  consisting  of  parts  which  pos- 
sessed these  qualities  in  an  intermediate  degree ;  the  carti- 
lage, for  instance,  was  not  so  dry  or  cold  as  the  bone,  &c.  It 
was  called  native,  when  it  was  received  at  conception ;  com- 
municated, or  unnatural,  when  changed  after  birth :  And 
the  chief  causes  which  induced  these  changes,  were  age,  the 
season  of  the  year,  climate,  and  habits.  It  was  called  per- 
manent, when  it  depended  on  the  formation  of  the  part ; 
temporary,  when  it  depended  on  the  fluids. 

The  intemperies,  or  bad  temperies,*  was  divided  into  the 
manifest  and  occult.  The  manifest  was  either  simple,  when 
only  one  quality  was  morbidly  increased,  producing  the 
warm,  dry,  or  cold  intemperies,  for  example  ;  or  complex, 
when  more  than  one  was  in  fault,  producing  the  dry  and  hot 
intemperies,  Sue.  The  occult  was  produced  by  some  hidden 
vice  ;  such  as  poison,  contagion,  &c. 

Besides  the  natural  humours,  upon  which  the  tempera- 
ments depended,  and  which  were  the  cause  of  most  diseases, 

*  "  Bona  temperies  est  pars  sanitatis,  quse  in  qualitatum  conveniente  constitu- 
tione  consistit." — "  Intemperies  est  morbus,  qui  in  qualitatum  colons  inconveni- 
entia  consistit."    Regii  Lib.  Med.  p.  5.  et  21. 


86 

the  ancients  likewise  admitted  the  existence  and  operation  of 
three  different  spirits,  the  natural,  the  vital,  and  the  animal ; 
and  also  the  same  number  of  faculties,  called  by  the  same 
name,  which  were  the  efficient  causes  of  the  different  actions, 
in  the  performance  of  which  the  spirits  were  the  instru- 
ments. 

The  natural  spirit  was  supposed  to  be  some  fine  exhalation 
from  good  blood,  or  some  very  delicate  substance,  prepared 
in  the  liver,  from  the  blood  and  air.*  This  was  the  thickest 
and  poorest  of  all  the  spirits,  and  was  contained  in  the  veins  : 
It  was  the  source  of  nutrition,  and  conducted  the  blood 
and  natural  faculty  to  all  the  different  parts  of  the  body. 
Some  physicians,  from  considering,  that  no  air  could  reach 
the  liver,  or,  if  it  did,  that  there  were  no  cavities  in  it,  to 
form  the  natural  spirit,  doubted  of  its  existence,  and  were 
confirmed  in  their  scepticism,  by  observing,  that  there  were 
no  ducts  leading  fiom  the  liver  capable  of  conveying  it  away ; 
for  they  could  not  believe,  that  the  thin  coats  of  the  veins 
could  contain  it.  These  difficulties,  however,  were  readily 
overcome  ;  for,  as  Hippocrates  had  declared,  that  "  omne 
corpus  transpiiabile  est  et  transfiuxile,"  it  followed,  that  the 
air  might  reach  the  liver,  through  the  diaphragm  ;  and  as  this 
spirit  was  thick,  it  followed,  that  the  veins  might  contain  it ; 
and,  being  slowly  produced,  that  no  cavity  was  requisite  for 
its  formation. 

The  vital  spirit  was  prepared  in  the  left  side  of  the  heart, 
from  air  and  blood  ;  and  it  was  ihis  union  which  produced 
the  pulse.  Physicians  readily  explained,  how  the  air,  taken 
in  by  inspiration,  was  prepared  in  the  lungs,  and  conveyed, 
by  the  arteria  venosa,  or  pulmonary  vein,  to  the  left  auricle 
of  the  heart :  But  they  found  it  more  difficult  to  settle  the 

*  Every  spirit  was  supposed  to  be  formed  from  the  blood,  the  thickest  parts 
farming  the  lowest  kind  of  spirit.  These  spirits  were  called  the  vehicles,  through 
which  the  different  faculties  operated. 


87 

controversies  which  arose  concerning  the  way  in  which  the 
blood  reached  that  cavity.  According  to  Galen,  the  blood  un- 
derwent some  attenuation  and  preparatory  change  in  the 
right  side,  whence  part  was  sent,  by  the  pulmonary  artery, 
to  nourish  the  lungs  ;  while  the  rest  was  transmitted,  through 
small  foramina  in  the  septum,  to  the  left  side.  Columbus  de- 
nied these  pores  to  exist,  and  maintained,  that  the  blood 
went  from  the  one  side  to  the  other,  by  the  circulation,  which 
is  now  admitted  and  established  as  a  fact.  Botallus  invented 
a  particular  duct  for  this  purpose  ;  whilst  Ulmus  laughed  at 
all  these  conjectures,  and  taught,  that  the  blood  underwent 
its  preparatory  change  in  the  spleen,  from  which,  by  means  of 
the  aorta,  it  reached  the  left  side  of  the  heart.  The  blood  and 
the  air  having,  then,  by  some  means  or  other,  got  together,  they 
formed  the  vital  spirit,  which  was  contained  in  the  arteries, 
where  it  could  be  felt  bounding  and  jumbling,  and  by  which  it 
was  conveyed  to  every  part  of  the  body,  vivifying  and  pre- 
serving those  parts  which  had  been  already  formed  by  the  na- 
tural spirit-  "  It  maintains  the  heat,  (says  Laurentius,)  brings 
out  whatever  is  lurking,  and  recruits  the  exhausted.  It 
shines  by  its  own  light,  and  displays  itself  in  every  part  of 
the  theatre  of  the  human  body  ;  and,  being  diffused  over  it, 
every  part  rejoices,  and  appears  with  a  rosy  colour.  When 
destroyed  or  intercepted,  the  whole  shivers,  becomes  pale, 
and  dies."* 

The  animal  spirit  was  tbe  finest  of  all,  and  could  not  be 
confined  within  the  coarser  vessels.  It  was  supposed,  for  a 
long  time,  to  be  prepared  in  the  anterior  ventricles  of  the 
brain,  from  the  vital  spirit,  which  ascended  by  the  carotid 
and  cervical  arteries,  and  the  air  which  was  taken  in  by  the 
nostrils  during  respiration.     That  this  was  the  case  was  con- 

*  I.aurentii  Opera,  p.  509. 


83 

sidered  lo  be  proved ;  because,  whether  the  carotid  Were 
tied,  or  the  breath  of  the  nostrils  stopped,  the  same  effect, 
namely,  apoplexy,  was  produced,  the  generation  of  this  spirit 
being,  in  both  instances,  equally  checked.  When  the  circu- 
lation of  the  blood  was  discovered,  and  the  arteries  were 
found  to  be  full  of  arterial  blood,  then  this  doctrine  of  the 
ancients  was  new-modelled-  The  arterial  blood,  which  was 
full  of  spirit,  was  sent,  by  the  vessels,  to  the  brain,  where  its 
watery  part  was  separated,  and  passed  off  by  the  pituitary 
gland,  whilst  its  spirit,  or  finer  part,  formed  the  animal 
spirit.* 

Some  denied  the  existence  of  this  spirit,  and  thought  that 
the  vital  spirit  was  sufficient  for  the  operation  of  the  body. 
Amongst  these  was  Argentei  ius,  who  accused  Galen  of  in- 
accuracy and  contradiction;  because,  in  one  place,  he  at- 
tributes the  generation  of  this  spirit  to  the  blood  ;  in  another, 
lo  the  air  ;  and  in  a  third,  to  the  vital  spirit,  which  was  said 
to  form  it,  at  one  place,  in  the  anterior  ventricles  ;  at  another, 
in  the  plexus,  or  substance  of  the  brain.  But  Laurent  iusf 
undertook  to  do  away  all  these  objections,  and  reconcile  the 
apparent  contradictions,  by  observing,  that  as  the  blood  was 
necessary  for  the  production  of  the  vital  spirit,  and  this 
spirit  and  air  necessary  for  the  generation  of  the  spirilus  ani- 
malis  ;  therefore,  all  the  three  might  properly  be  mentioned 
by  Galen ;  and  as  for  the  objection,  on  account  of  the  differ- 
ent places  in  which  it  was  said  to  be  produced,  this  also  was 
a  quibble  ;  because  it  was  prepared  in  the  plexus  and  anterior 
ventricles,  refined  in  the  third  ventricle,  peifected  in  the 


-'   De  le  boe  Sylvius  Opera  Medica,  p.  20. 

•J-  Laurent.  Opera  Omnia,  p.  C52. — This  author  was  particularly  angry  at  Ar 
genterius,  because  he  had  denied,  that  the  fluid  which  came  down  the  nose,  was 
the  peculiar  excrement  of  the  brain,  but  was  generated  in  the  liver.  "  Meher- 
cule,  (says  he,)  iu  doctiina  Argcnterii  nullus  est  iufuadibuli.  et  gtanduhc pituita- 
ike  in  ccrebro  tcmperati.-dmo  usus."  p.  Gb'4. 


89 

fourth,  and  diffused  finally  through  all  the  substance  of  the 
brain  and  nerves. 

This  spirit,  says  Van  Helmont,  is  the  impetum  faciens  of 
Hippocrates,  which  holds  the  key  of  life  in  its  hand.  In  the 
brain,  it  produced  what  are  called  the  internal  senses  ;  when 
carried  out  of  it  by  the  nerves,  it  was  the  cause  of  motion, 
and  the  external  senses.  It  has  been  already  mentioned, 
that  it  was  equivalent  to  the  nervous  energy  of  the  modern 
schools. 

Upon  these  humours  and  spirits,  then,  did  the  ancients 
found  their  system  of  physic.*  Obstruction  to  the  free  mo- 
tion of  the  animal  spirit,  produced  palsies,  apoplexies,  and 
convulsions  ;  whilst,  when  the  vital  spirit  was  affected,  the 
heat  of  the  parts,  and  their  life,  could  no  longer  be  support- 
ed, and  mortification  took  place.  A  redundancy  of  blood 
produced  phlegmon  :  The  pituita  caused  dropsy  ;  or,  when 
the  blood  was  full  of  it,  from  "  multiplied  crudities,"  then 
it  fell  upon  the  joints,  and  swelled  them  :  The  choler  pro- 
duced jaundice,  dysentery,  and  erysipelas ;  whilst  the  atra 
bilis,  or  melancholic  humour,  caused  cancers  ;  and,  by  "  its 
fuliginous  vapours  ascending  to  the  brain,"  brought  on  many 
disorders.  These  diseases  were  produced  chiefly  by  an  in- 
creased quantity  of  these  humours  ;  but,  when  they  corrupt- 
ed or  changed,  then  no  one  pretended  to  estimate  the  evil 
which  might  follow.  Nay,  not  satisfied  with  corrupting  them- 
selves, these  humours  enticed  foreign  contagions  to  combine 
with  them,  the  venereal  virus  lurking  in  the  pituita,  whilst 
the  measles  lodged  in  the  choler. 

The  practice  which  naturally  followed  from  this  theory, 
was  to  expel  the  morbid  humour ;  but  this  they  could  not  do, 
until  by  remedies,  or  the  process  of  nature,  it  was  concocted' 
and  prepared  for  evacuation. 

*  Disease,  said  they,  is  produced,  by  either  a  bad  temperies,  or  by  mfalfenrij- 
tion  of  a  part. 

VOi.   I>  M 


90 

Although  these  were  the  prevailing  doctrines  concerning 
the  cause  of  diseases,  in  the  ancient  schools,  yet  most  phy- 
sicians admitted  the  co-operation  of  an  intelligent  principle.* 
To  this  principle,  Hippocrates  gave  the  name  of  nature, 
which  he  considers  as  of  an  excellent,  and  almost  divine 
quality.  This  principle,  we  are  informed,  is  heat  ;f  by 
which  term,  however,  we  are  not  to  understand  him  as  mean- 
ing common  fire,  but  a  principle  sui  generis ;  for  the  ancients 
used  this  term  in  a  very  extensive  sense.  Thus,  Aristotle:}: 
tells  us,  that  the  soul  of  man  is  heat  ;  but  cautions  us  from 
believing,  that  he  means  exactly  any  thing  which  we  have 
ever  seen  in  another  situation.  By  comparing  some  passages 
of  Hippocrates  with  each  other,  and  with  the  writings  of  the 
philosophers  who  lived  about  that  time,  we  shall  find  it  to  be 
most  probable,  that,  by  the  operations  and  interference  of  na- 
ture, he  meant  the  agency  of  the  soul  ;||  a  doctrine  which 


*  "  Mediciaa  id  quod  molestat  tollit,  id  a  quo  homo  aegrotat  auferens,  sanuia 
facit.    Natura  eadem  sua  sponte  novit."    Hip.de  Dieta. 

j  The  original  theory  of  animal  heat,  was,  that  a  calor  nativus,  or  innate  heat, 
existed  in  the  left  ventricle  of  the  heart,  which  went  out  by  the  vessels,  and  sup- 
ported the  body. 

t  "  There  is  a  certain  animal  heat  diffused  through  the  universe,  so  that  all 
things  are,  in  a  manner,  full  of  mind  ;  on  which  account,  they  may  be  quickly 
completed  into  animals,  when  they  have  received  a  portion  of  this  heat.  This  is 
not  fire,  nor  any  thing  like  it,  but  a  spirit  which  is  in  the  semina,  or  elementary 
principles  of  bodies."    Aristotle  de  Generut.  A?iim.  lib.  iii.  c.  11.  et  lib.  ii.  c.  3. 

jj  The  left  ventricle  is  larger  than  the  right,  and  is,  as  it  were,  gnawed.  "  Nanfe 
insitus  a  natura  iguis  non  est  in  dexti#.  — "  Mens  enim  hominis  in  sinistro  ven- 
triculo  insita  est,  et  reliquae  animfe  imperat."    De  Corde. 

"  Et  videtur  sane  mibi  id  quod  calidum  vocamus,  immortale  esse,  et  cuncta  in- 
telligere,  et  videre,  et  audire,  et  scire  omnia  turn  praesentiii  turn  futura." 

.  De  Carnibus. 

"  Ignis  enim  omnia  peF  omnia  movere  potest.      De  Dieta. 

Some  were  unwilling  to  admit,  that  Hippocrates  really  supposed  that  the  soul 
had  its  seat  in  the  breast,  and  imagined,  that  he  either  said  so  incompliance  with 
common  language,  or  because  the  great  instrument  of  the  mind  (heat)  resided 
there :  But  by  comparing  his  words  with  the  ideas  of  Aristotle,  concerning  the 
nature  of  the  soul,  it  will  appear,  that  he  really  believed  the  heart  to  be  the  seat 
Of  the  aniina,  although  its  mental  operations,  or  faculties,  were  exercised  in  the 


91 

was  more  expressly  repeated  by  StaW,  and  adopted  by 
Mead,*  and  many  of  the  more  modern  physicians. 

The  notion  of  all  the  humours  being  diseased,  was  at  last, 
in  a  great  measure,  overlooked,  or  attended  to  only  by  the 
bye ;  and  the  state  of  the  blood  began  to  be  considered  as 
almost  the  only  immediate  cause  of  disease.  The  pathology 
of  Sydenham  was  founded  entirely  on  the  condition  of  the 
blood,  and  the  operation  of  the  vis  medicatrix  naturae. 
When  a  contagion  was  introduced  into  the  blood,  then  nature 
excited  a  fermentation,  in  order  to  concoct,  and  finally  expel 
it.  This  she  did,  sometimes  quickly,  sometimes  more  slow- 
ly, generally  by  the  help  of  a  fever,  terminating  by  looseness, 
or  sweating.  But  in  this,  as  well  as  in  every  other  theory 
which  admits  the  assistance  of  nature,  we  find,  that  the  cause 
of  the  disease  is  most  ridiculously  misapplied  ;  for  they  by  no 
means  prove,  that  the  peccant  matter  taken  into  the  blood, 
would  of  itself  be  fatal  ;  but  they  most  abundantly  allow, 
that  the  interference  of  nature,  which  excites  a  dangerous 
disease,  is  often  mortal,  and,  not  unfrequently,  the  cause  of 
the  most  lasting  calamities.     "  What  is  gout,  (says  Syden- 


brain ;  and  also,  that  the  anima  consisted  of  a  somewhat,  which  he  denominated 
heat. 

Anaxagoras,  more  decidedly,  said,  that  nature  was  the  mind  or  soul,  "  mentem 
appellat."  Galen  said,  that  nature  was  a  warm  spirit,  "Natura  item  est  spiritus 
ualidus."    Zeuo,  more  bold,  declared  it  to  be  common  fire. 

*  "  Such  is  the  composition  of  our  fabric,  that  when  any  tiling  pernicious  has 
got  footing  within  the  body,  the  governing  mirJd  gives  such  an  impulse  to  those  in- 
struments of  motion,  the  animal  spirits,  as  to  raise  those  commotions  in  the  blood 
and  humours,  which  may  relieve  the  whole  frame  from  the  danger  in  which  it  is 
involved."    On  the  Small  Pox. 

In  pestilential  fevers,  "  the  mind  hurries  to  the  assistance  of  the  labouring 
frame,  fights  against  the  enemy,"  &c.     Med.  Precept. 

"  Quis  non  videt  in  acutis  pulsum  vibrare  vehementius,  sanguinem  fervfire, 
turbari  omnia  ?  Haec  ipsa  vero  virtus  natune  est,  qu<e  alienum  et  cruduni  sic  po- 
tentius  subigit  et  suis  nocendi  viribus  exuit,  vel  si  exnere  penitus  non  potest,  ne 
novas  turbas  moliatur,tanquam  indignum  arvis  suis  caloruin  variis  viis  inter  criti- 
pa,  ut  vocant,  molimina  expellit."  RichUri  Opxtscula^  torn,  i.  p.  313. 


62 

ham,)  but  a  contrivance  of  nature  to  purify  the  blood  of  old 
men,  and  to  purge  the  deep  parts  of  the  body."  Few  peo- 
ple would  thank  Dame  Nature  for  this  friendly  purgation. 

The  idea  of  concoction,  and  assimilation,  was  likewise 
adopted  by  Boerhaave,  and  is  taught  still  by  some  modern 
authors.  But  this  great  physician  called  in  the  additional  aid 
of  other  principles,  namely,  the  viscidity  and  lentor  of  the 
blood,  and  the  error  loci  of  its  globules.  This  doctrine, 
which  will  be  more  particularly  illustrated  in  the  theory  of 
inflammation,  had,  in  its  principle,  occurred  to  Asclepiades, 
who  made  disease  consist  in  a  want  of  proportion  betwixt  his 
atoms  and  the  pores  through  which  they  were  to  pass. 
These  doctrines  of  the  origin  and  cause  of  disease,  produced 
the  most  unhappy  practice.  Venesection,  emetics,  purges, 
and  sudorifics,  were  rapidly  prescribed,  one  after  another,  to 
avert  the  danger,  and  the  urine  carefully  'examined,  to  mark 
the  progress  of  the  concoction  ;  whilst  ^uch  remedies  as 
tended  more  effectually,  and  directly,  to  check  the  disease, 
were  proscribed  and  forbid,  because  they  produced  no  sen- 
sible evacuation. 

The  whole  of  these  conjectures  were  evidently  founded" 
upon  ignorant  and  mistaken  views  of  the  animal  economy. 
Unacquainted  with  the  true  laws  of  the  living  system,  they 
reasoned  upon  the  supposition  of  the  blood  being  subject  to 
the  same  changes,  when  circulating  in  the  vessels  of  a  man, 
as  when  collected  and  preserved  in  their  phials  and  matrasses. 
They  knew  not  the  true*  history  of  our  functions,  nor  the 
real  cause  of  all  the  varied  phenomena  of  life.  Their  heads 
were  full  of  nothing  but  spirits,  and  humours,  and  ferments  ; 
and  their  systems  were  built  entirely  on  plethora,  and  inani- 
tion, and  cacochymy. 

When,  at  last,  they  began  to  see  more  clearly  the  agency 
of  the  nervous  system,  and  to  abandon  their  belief  in  the  co- 
operation, of  different  spirits  to  produce  the  actions  of  lifea 


93 

they  found  it  necessary  to  allow,  that  diseases  have  their 
chief  seat  in  the  nervous  system  ;  but  being  sill  unwilling  to 
give  up  their  favourite  doctrine  of  morbid  humours,  they  as- 
serted, that  these  still  existed,  but  operated  through  the  me- 
dium of  the  nervous  energy.  Hoffman  maintained  the  seat 
of  diseases  to  be  in  "  ihe  living  solid ;"  but  avowed  the 
agency  of  diseased  blood.  Cullen,  who  improved  this  theo- 
ry, acknowledged,  in  many  instances,  the  derangement  of 
the  fluids  :  Nor  is  there  almost  any  system,  even  in  the  pre- 
sent day,  in  which  it  is  not  more  or  less  allowed. 

That  medicines  may,  in  several  instances,  be  absorbed, 
and  mixed  with  the  blood,  will  be  allowed  by  all ;  but  that 
they  thus  exert  the  whole  of  iheir  influence,  cannot  be  ad- 
mitted ;  nor  will  it,  by  any  means,  be  considered  as  true, 
that  either  medicines,  or  contagions,  act  by  changing  the  na- 
ture, or  altering  the  properties  of  this  fluid,  until  it  be  proved* 
that  the  blood  is  not  circulating  in  vessels  possessed  of  a 
power  of  acting  on  it,  and  until  it  be  established,  that  the 
blood  is  completely  an  extraneous  substance,  subject  to  all 
the  laws  of  foreign  matter,  and  making  no  part  of  the  living 
system.  That  in  disease  the  blood  does  change,  to  a  certain 
degree,  is  ascertained  ;  but  these  changes  are  not  the  con- 
sequence of  any  direct  action  upon  it,  by  contagions,  or  me- 
dicines; they  are  analogous  to  the  alterations  which  take 
place  in  the  rest  of  the  system,  and  depend  upon  the  same 
cause,  namely,  a  general  affection  of  the  living  principle. 
One  of  the  most  evident  changes  induced  upon  the  blood, 
and  one  which  might  be  supposed  to  favour  the  doctrine  of 
chemical  changes,  being  induced  directly  by  contagion,  is  its 
conversion  from  veinous  into  arterial,  and  from  arterial  into 
veinous  ;  but  even  these  changes  are  very  far  indeed  from 
being  proved  to  depend  upon  chemistry,  independently  of 
the  living  principle.  It  is  considered  as  proved,  that  the 
veinous  blood  is  rendered  arterial,  by  the  oxygen  of  the  at- 


94 

mosphere  being  combined  with  certain  principles  of  the 
blood,  and  carrying  .hese  off,  and  that  it  is  again  rendered 
veinous,  by  the  addition  of  these  substances  ;  but  it  is  far 
indeed  from  being  proved,  that  these  combinations,  and  ad- 
ditions, take  place  independently  of  the  action  of  !he  vessels  ; 
nor  is  it  even  ascertained,  that  the  use  of  respiration  is  to 
purify  the  blood  from  these  substances.  Had  this  been  all 
which  was  requisite,  they  could  have  been  removed  by  some 
particular  excretion,  as  we  see,  in  part,  exemplified  in  the 
formation  of  the  bile.  The  production  and  extrication  of 
these  substances,  are,  however,  very  much  connected  with 
the  process  of  respiration ;  for,  we  find,  that  whenever  the 
arterial  blood  is  converted  inio  veinous,  which  transition 
takes  place  suddenly,  certain  substances  are  found  in  it ;  and 
these  again  are  evolved,  during  the  instant  of  its  being 
changed  into  arterial.  I  formerly  mentioned  my  supposition 
of  the  production  of  vitality  being  the  main  intention  of  the 
Function  of  respiration.  This  principle  seems  to  be  yielded 
to  the  nerves,  by  the  minute  arteries ;  and,  at  the  same  in- 
stant, the  blood  becomes  black  and  veinous.  There  is  then 
this  connexion  betwixt  the  purification  of  the  blood  from  car- 
bone  and  hydrogene,*  and  the  arterialization  of  it,  or  the 
furnishing  of  the  vital  principle,  that  both  take  place  at  the 
same  time,  and  that  the  one  process  is,  perhaps,  instrument- 
al in  producing  the  other,  f 

The  blood  is  to  be  considered  as  a  living  substance,  pos- 
sessed of  peculiar  properties,  and  endowed  with  the  power 


*  Some  deny  that  hydrogene  is  found  in  the  Wood  ;  but  other  experiment* 
prove,  that  it  does  make  a  part  of  veinous  blood. 

t  In  the  foetus,  these  changes  on  the  blood  took  place  without  the  assistance  of 
the  air,  by  the  peculiar  operation  of  the  placenta,  in  which  the  blood  is  both 
freed  from  its  carbone  and  hydrogene,  and  likewise  acquires  vitality,  and  the  ma- 
terials of  nourishment.  Some  suppose,  that  this  depends  upon  the  foetal  blood 
coming  in  contact  with  the  maternal  in  the  placenta ;  but  this  is  by  no  means 
proved. 


95 

of  preserving  its  specific  nature,  in  common  with  other  bodies. 
It  is  only  whilst  it  remains  in  this  living  state,  that  it  is  use- 
ful to  the  system  ;  for,  if  its  nature  be  changed,  it  is  no  long- 
er that  fluid  which  is  requisite  for  life.  It  cannot  even  be 
rendered  all  veinous,  which  is  the  most  natural  and  easy 
change  which  it  can  undergo,  without  immediate  death  being 
the  consequence  to  the  animal.  How  unphilosophical,  how 
absurd,  then,  must  it  be,  to  talk  of  fermentations,  assimila- 
tions, and  putrefactions  of  the  blood  ;  and  how  thoroughly 
ignorant  of  the  animal  economy  must  they  be,  who  can  use 
such  language,  or  have  recourse  to  those  miserable  explana- 
tions of  the  cause  of  disease  ! 

From  the  whole  of  these  considerations,  we  may  reasona- 
bly conclude,  that  we  are  to  look  for  the  origin  and  seat  of 
disease,  not  in  the  ideal  habitation  of  humours  and  spirits, 
not  in  the  chemical  changes  or  fermentations  of  the  blood, 
but  in  the  nervous  system. 

Some  of  those  who  attended  most  to  this  system,  attri- 
buted much  to  spasmodic  actions  ;  some  admitted  peculiar 
and  varied  actions  of  the  nervous  system;  whilst  others  re 
ferred  disease  entirely  to  the  different  degrees  of  excitement, 
as  they  called  it,  of  the  living  principle. 

The  first  of  these  suppositions  was  very  ably  supported 
by  Dr.  Cullen,  who  believed,  that,  in  many  instances,  the  vis 
medicatrix  natura*,  in  order  to  get  quit  of  some  noxious  pow- 
er, formed  a  spasm  on  the  extreme  vessels,  the  consequence 
of  which  was,  an  increased  action  of  the  heart  and  arteries, 
in  order  to  overcome  this,  and  cure  the  disease.*  How  far 
this  theory  explains  the  different  circumstances  attending  in- 
flammation, and,  consequently,  how  far  it  is  founded  upon 
facts,  and  good  reasoning,  will  afterwards  come  to  be  con- 
sidered; and,  therefore,  to  prevent  repetition,  I  shall  only 

*  Ffrst  lines,  &c.  vol.  i>  chap.fi. 


96 

observe,  in  this  place,  that  the  Cullenian  doctrine  is  subject 
to  this  objection,  in  common  with  others,  which  admit  the 
operation  of  an  intelligent  principle  in  the  cure  of  diseases  ; 
that  the  whole  series  of  dangerous  symptoms,  or,  in  other 
words,  the  disease  itself,  is  produced,  not  directly  by  the  ap- 
plication of  hurtful  agents,  but  by  the  supposed  interference 
of  the  healing  power  of  nature,  quod  erat  absurdum. 

Mr.  Hunter  has  given  us  no  regular  system  of  pathology ; 
but,  by  gleaning  his  works,  we  learn,  that  he  considers,  first, 
that  every  operation  of  the  body  is  an  action  of  the  living 
principle  ;*  second,  that  no  two  actions  can  take  place  at  the 
same  time,  and  in  the  same  part,  more  than  two  different  mo- 
tions in  a  piece  of  matter  ;f  third,  that  a  disease  is  pro- 
pagated from  a  £art  to  the  whole,  by  means  of  the  sympathy 
which  exists  through  the  whole  body,  by  the  diffused  prin- 
ciple of  life.  This  principle  "  is,  as  it  were,  diffused  through 
the  whole  solids  and  fluids,  making  a  necessary  constituent 
part  of  them,  and  forming  with  them  a  peifect  whole,  giving 
to  both  the  power  of  preservation,  the  susceptibility  of  im- 
pression, and,  from  their  construction,  giving  them  conse- 
quent reciprocal  actions.  This  is  the  matter  which  prin- 
cipally composes  the  brain."J 

Upon  the  two  first  propositions  I  shall  make  no  remark, 
because  I  have  already  endeavou  ed  io  establish  and  illustrate 
them.  They  are,  in  my  opinion,  the  most  rational  foundation 
upon  which  a  system  of  physic  can  be  reared,  and  are  so 
self-evident,  that  they  occurred  o  me  soon  afiei  I  began  to 
study  medicine,  and  before  I  had  any  oppo.  tunuy  of  know- 
ing that  they  were  proposed  by  Mr.  Humer.  Upon  ,he 
third  proposition,  I  have  only  to  repeat  the  remark  which  I 
formerly  made,  that  it  teaches  a  very  confined  idea  of  life, 


*  Hunter  on  the  Blood,  &c.  p.  3. 

f  Ditto. 

1  Ditto,  p.  69 


97 

which,  according  to  this  supposition,  can  only  be. united  with 
a  certain  structure,  the  existence  of  which,  in  many  cases,  is 
far  from  being  proved. 

Dr.  Brown  attempted  to  simplify  medicine,  and  reduce 
every  disease  to  one  of  two  causes.*     He  began  by  observ- 
ing, that  "  a  certain  quantity  of  excitability  (or  living  prin- 
ciple) is  allotted  to  every  one  at  birth."f — "  That  this  is 
acted  upon  by  different  powers,  which  are  termed  exciting 
powers  ;  and  their  effect  on  the  excitability  is  called  excite- 
ment."^:— "  This  mutual  relation  obtains  betwixt  excitability 
and  excitement,  that  the  more  weakly  the  powers  have  acted, 
or  the  less  the  stimulus  has  been,  the  more  abundant  the  ex- 
citability becomes ;  the  more  powerful  the  stimulus,  the  ex- 
citability becomes  the  more  exhausted."|| — "  In  both  of  these 
circumstances,  weakness  takes  place,  which,  in  the  first  case, 
is  called  direct,  in  the  second,  indirect."** — "  It  is  the  ex- 
,  citement  aloney  through  its  varying  degrees,  that  produces 
either  health,  disease,  or  recovery."ff — "  The  general  dis- 
eases, arising  from  excessive  excitement,  are  called  sthenic  ; 
those  that  originate  from  a  deficient  excitement,  asthenic. 
Hence  there  are  two  forms  of  diseases,  and  both  are  always 
preceded   by    predisposition."JJ — "  That  this  is  the  only 
real  origin  of  diseases  and  predisposition,||!|  is  proved,  by 
the  same  powers  which  produce  any  disease  or  predisposi- 
tion, also  producing  the  whole  set  of  diseases  to  which  it  be- 
longs  ;  and  by  the  same  remedies  which  cure  any  disease  or 


*  This  doctrine  had,  in  its  principle,  occurred  to  Themison,  the  founder  of  the 
Methodic  sect,  who  maintained,  that  diseases  depended  upon  either  an  overbra^ 
Sag  or  a  relaxation  of  the  system. 

f  Elements  of  Medicine,  Par.  xviii.  p.  7. 

\  Par.  xvi.  p.  'j.  \\  Par.  xxiv.  p.  13. 

**  Par.  xxxv.  and  xlv.      ft  Par-  kdi«  p.  50. 

\\  Par.  lxvi. 

||!|  "  Predisposition  is  a  state  intermediate  betwixt  perfect  health  and  disease. 
The  powers  producing  :.'  are  the  same-  with  thosp  which  pro^irp  disease."  Pa*- 
Ixxiii.  p.  59. 

rot.    !<•  S 


predisposition,  also  curing  all  the  diseases  and  predisposition* 
of  its  respective  form."*  The  operation  of  all  contagions 
is  stimulant,  and  "  no  remedies,  but  those  that  cure  diseases 
produced  by  the  usual  noxious  powers,  remove  those  sup- 
posed to  be  induced  by  contagion."! — "  Though. the  fluids 
may  be  corrupted,  yet  this  is  not  a  cause,  but  an  effect  of 
weakness.  Wine,  bark,  &c.  by  strengthening  the  vessels, 
purify  their  contents."^:  In  the  indication  of  cure,  the  only 
regard  to  be  had  to  morbific  matter,  is  to  allow  time  for  its 
passing  out  of  the  body ;  and  that,  whether  it  stimulates  or 
debilitates,  or  gives  the  peculiar  form  to  the  disease,  thereby 
adding  a  local  to  a  general  complaint  ;  for,  if  the  general  dis- 
ease be  properly  healed,  the  eruptions,  inflammation,  ulcers, 
will  give  way  to  the  happy  effects  of  the  general  cure.|| 

To  conclude,  "  the  whole  and  sole  province  of  a  physician, 
is  not  to  look  for  morbid  states  and  remedies,  which  have  no 
existence,  but  to  consider  the  deviation  of  excitement,  from 
the  healthy  standard,  in  order  to  remove  it  by  the  proper 
means."** — "  Such  is  the  simplicity  to  which  medicine  is 
thus  reduced,  that  when  a  physician  comes  to  the  bed-side 
of  a  patient,  he  has  only  three  things  to  settle  in  his  mind ; 
first,  whether  the  disease  be  general  01  local ;  secondly,  whe- 
ther it  be  sthenic  or  asthenic  ;  third,  what  is  its  degree."ff 

Upon  this  system  I  would  have  expected,  that  very  little 
observation  would  have  been  necessary  to  show  its  absurdity ; 
and  I  should  have  done  no  more  than  merely  state  it,  were 
we  not  every  day  told  of  the  progress  which  it  is  making. 
One  great  and  leading  error,  which  every  one  will  observe, 
is,  that  he  supposes  the  more  life  or  excitability  that  any  per- 
son has,  the  nearer  he  is  to  death.^     Here  the  dependence 


*  Par.  lxvii.  p.  51.  f  Par.  xxi.  p.  10. 

X  Par.  cxviii.  \\  Par.  xcvii.  p.  81. 

•*  Par.  cxlix.  p.  138.  ft  Par.lxxix.  p. 6-1. 

it  Par.  xxiv. 


•99 

of  energy  for  its  production,  upon  the  continuance  of  natural 
action,  is  overlooked.  When  the  action  is  too  little,  energy 
is  not  produced  ;  when  the  action  is  too  great,  or  in  a  morbid 
degree,  its  production  is  not  only  injured,  but  more  is  ex- 
pended than  can  be  generated.  These  are  the  effects  pro- 
duced by  a  deficiency  or  increase  of  action,  to  a  morbid  de- 
gree. There  can  be  no  accumulation  of  life,  or,  were  it  to 
take  place,  as  from  want  of  food,  for  instance,  then  it  follows, 
that  any  stimulus  given  before  death,  should  preserve  life; 
and  the  living  power  being  very  abundant,  the  person  ought 
easily  to  bear  a  strong  stimulus,  which  is  far  from  being  the 
case. 

.  This,  however,  is  a  very  trifling  mistake,  when  compared 
to  the  next  error,  which  teaches,  that  all  diseases  consist  en- 
tirely in  different  degrees  of  excitement  of  this  life,  and  not 
in  any  new  and  peculiar  operation  or  action  which  it  per- 
forms. Do  not  all  the  phenomena  of  fevers,  small-pox,  sy- 
philis, and  almost  every  disease,  controvert  this  doctrine  in 
the  strongest  manner  1  Will  every  stimulant  cure  the  vene- 
real inflammation  ?  Will  wine  cut  short  the  progress  of  a 
fever  ?  Is  it  debility  alone  that  is  to  be  regarded  in  the 
treatment  of  a  fever,  and  stimulants  alone  that  are  to  be  ad1- 
ministered?^  I  will  venture  to  affirm,  that  if  this  practice 
be  followed  out,  no  mart  can  estimate  the  lives  whic^i  shall  be 
lost.  If  debility  alone  produces  fevers,  I  will  demand  of  the 
Brownonian,  why,  in  the  course  of  a  fe«'  hours,  the  pulse 
falls  from  its  great  frequency  almost  to  the  natural  standard, 
and  that  without  any  stimulant  Mng  exhibited,  or  the  patient 
feeling  in  the  least  degree  stronger,  or  being  able  to  make 
one  greater  exertion  ?  I  shudder  when  I  recollect  the 
scenes  which  I  have  witnessed,  and  the  miserable  effects  of 
the  blind  Brownonian  practice.     Wine  and  opium,  I  do  most 

*  Par.  dclxxx. 


100 

sincerely  believe,  are,  in  the  hands  of  Brown's  disciples, 
what  fire  and  sword  are  in  the  battles  of  the  cruel. 

From  the  apparent  simplicity  of  this  theory,  the  student 
is  led  to  neglect  the  various  operations  of  the  system,  and 
disregard  the  niGcr  symptoms  and  distinctions  in  diseases, 
being  taught,  that  his  sole  province  is  to  inquire  into  the  de- 
gree of  excitement,  that  he  may  bleed  in  one  case,  and 
give  wine  in  another.  And,  to  remove  any  scruples  which 
may  still  remain  in  his  mind,  concerning  the  radical  differ- 
ences of  diseases,  he  is  assured,  in  the  strongest  manner,  that 
in  no  respect  are  they  different,  except  in  the  circumstances 
of  strength  or  weakness ;  that  there  are  no  specific  opera- 
tions of  the  living  system,  no  alterations  even  in  the  fluids, 
(which  were  to  the  humouralist  what  the  nervous  system 
ought  to  be  to  the  true  physiologist,)  modifying  the  disease  ; 
and  that,  therefore,  he  need  not,  on  this  account,  think  of 
varying  his  treatment  ;  for  all  eruptions  and  conditions,  thus 
Induced,  will  yield  to  the  sthenic  or  asthenic  plan. 

From  this  leading  error  in  the  system,  it  is  astonishing  how 
little  able  many  Brownonians  are  to  distinguish  betwixt  two 
dissimilar  diseases,  which  have  some  general  symptoms  in 
common.  This,  it  may  be  said,  ought  to  be  placed  to  the 
account  of  the  stupidity  of  the  physician;  but,  certainly, 
the  doi^rines  which  this  system  teach,  are  well  calculated  to 
increase  th^  natural  stupidity,  by  giving  little  incentive  to 
investigation. 

Of  late,  this  theory  has  been  modified,  by  the  introduc- 
tion of  chemical  principles,  mally  diseases  being  attributed 
to  an  increase,  or  deficiency,  of  oxygen,  as  well  as  a  devia- 
tion from  the  due  state  of  excitemem.  Whether  oxygen  be, 
or  be  not  present,  in  greater  and  less  quantities,  at  different 
times,  is  a  point  which  I  shall  not  inquire  into  ;  but  I  think 
it  is  pretty  evident,  that  if,  in  any  disease,  there  be  too  much, 
or  too  little,  of  any  chemical  principle  present,  or  employed 


101 

in  the  whole  system,  or  a  part  of  it,  the  mere  addition  or 
subtraction  of  part  of  that  principle  will  not  inevitably  cure 
the  disease,  because  we  do  not  thus  alter  the  action  which 
constitutes  the  disease ;  and  this  redundancy,  or  deficiency, 
is  a  symptom,  and  not  a  cause.  We  never  can  prevent  the 
introduction  of  what  may  be  called  the  chemical  elements 
into  the  body  by  any  means  whatever.  They  are  all  essen- 
tial to  our  existence,  and  the  modification  which  they  receive 
will  continue  as  long  as  the  action  exists  which  regulates  or 
produces  it,  whatever  chemical  or  mechanical  contrivances 
we  may  fall  upon  to  prevent  it.  If  phthisis  depended  upon 
the  presence  of  too  much  oxygen  in  the  blood,  which  is  not 
proved,  we  could  not  cure  it  by  breathing  an  impure  air,  be- 
cause the  oxygen  which  the  atmosphere  did  contain  would 
be  more  completely  consumed ;  and  if  we  gave  less  than  the 
quantity  necessary,  respiration  would  cease  to  be  properly 
performed,  just  as  it  would  in  health  be  injured  by  a  propor- 
tionate diminution.  It  is  likewise  a  very  mistaken  notion, 
that  because  hydrocarbonate,  and  other  airs,  mixed  with  that 
which  we  breathe,  give  relief  sometimes,  therefore  a  dimin- 
ished quantity  of  oxygen  is  useful.  They  forget  that  these 
airs  are  very  powerful  medicines,  and  act  independently  of 
their  mechanically  lessening  the  quantity  of  oxygen,  by  oc- 
cupying its  place.  The  proper  argument  would  be,  to  prove, 
that"  the  poor,  in  their  low,  ill  aired  habitations,  live  longer  in 
consumption  than  the  rich,  winch  few  will  believe.  It  is 
likewise  conjectured,  that,  by  adding  the  chemical  principle 
in  superabundance,  we  induce  the  disease  or  condition,  which 
is  supposed  to  depend  upon  the  presence  of  this ;  as,  for  in- 
stance, it  is  supposed  that  too  much  oxygen  will  produce 
phthisis  ;  if  so,  the  purest  air  ought  to  be  most  unhealthy, 
and  those  who  live  in  the  country,  and  on  mountains,  ought 
to  be  most  subject  to  consumption.  So  sanguine  is  one  gen- 
tleman in  his  belief  of  this  doctrine,  that  he  hopes,  cbemi- 


102 

cally,  to  suspend  the  laws  of  nature,  and  make  the  trees  distil 
butter  and  cream.  This  would  be  a  valuable  discovery  for 
the  Hindoos  ;  for,  by  a  similar  process,  they  might  procure 
beef  and  mutton,  without  taking  existence  from  an  animated 
being.  I  know  only  one  story  which  can  match  this,  and  in- 
deed the  whole  theory,  and  that  is,  the  old  tale  of  a  town, 
where  roasted  pigs  run  through  the  streets  with  knives  and 
forks  stuck  in  their  posteriors,  crying,  Come  eat  us  !  Come 
eat  us .' 

The  last  theory  which  I  shall  take  notice  of,  is  that  of  the 
very  ingenious  Dr.  Darwin  ;  which,  in  one  respect,  is  simi- 
lar to  the  Brownonian  doctrines,  but  differs  in  the  particular 
steps,  leading  to  the  general  principles. 

To  examine  this  theory  fully,  would,  on  account  of  its 
complexity,  require  more  time  than  is  compatible  with  my 
present  purpose.  I  can,  therefore,  only  give  here  the  out- 
lines, and  most  fundamental  parts  of  the  doctrine. 

"  The  whole  of  nature*  (according  to  Dr.  Darwin")  may 
be  supposed  to  consist  of  two  essences,  or  substances,  one  of 
which  may  be  termed  spirit,  and  the  other  matter.  The 
former  of  these  possesses  the  power  to  commence,  or  pro- 
duce motion,  and  the  latter  to  receive  and  communicate  it. 
So  that  motion,  considered  as  a  cause,  immediately  precedes 
every  effect  ;  and,  considered  as  an  effect,  it  immediately 
succeeds  every  cause." — "  The  motion  of  matter  may  be 
divided  into  two  kinds,  primary  and  secondary.  The  secon- 
dary motions,  are  those  which  are  given  to,  or  received  from 
other  matter  in  motion." — "  The  primary  motions  of  matter 
may  be  divided  into  three  classes  ;  those  belonging  to  gra- 
vitation,  to  chemistry,  and  to  life  ;  and  each  class  has  its 
peculiar  laws." — "  This  last  class  of  motion  is  the  subject 
of  the  following  pages."     Motion,  which  is  defined  "  to  be 

*  Zoonomia,  vol.  i.  p.  5. 


103 

a  variation  of  figure,"*  is  divided,  in  the  animal  body,  into 
two  classes : 

First,  Sensorial  motions,  or  those  peculiar  to  the  sensori- 
um,  which  constitute  the  sensation  of  pleasure  and  pain,  and 
which  constitute  volition,  and  cause  the  fibrous  contractions, 
in  consequence  of  irritation,  or  association.  These  motions 
are  not  fluctuations  of  the  spirit  of  animation,  nor  vibrations, 
nor  equilibrations,  but  changes,  or  motions  of  it,  peculiar  tor 
life.f  They  are  the  faculties,  or  motions  of  the  sensorium, 
to  be  afterwards  mentioned. 

Second,  Fibrous  motions,  which  include  the  motions  of 
the  muscles,  and  organs  of  sense,  J  which  are  contractile,  and 
which,  by  their  various  configurations,  give  us  ideas. 

The  spirit  of  animation  is  the  immediate  cause  of  the  con- 
traction of  animal  fibres.  It  resides  in  the  brain  and  nerves, 
and  is  liable  to  general  and  partial  diminution,  or  accumula- 
tion.    It  is  also  called  the  sensorial  power.|| 

The  stimulus  of  external  bodies  is  the  remote  cause  of  this 
contraction. 

A  certain  quantity  of  stimulus  produces  irritation,  which 
is  an  exertion  of  the  spirit  of  animation,  exciting  the  fibres 
into  contraction. 

A  certain  quantity  of  contraction  of  animal  fibres,  if  it  be 
perceived  at  all,  produces  pleasure  ;  a  greater,  or  less  quan- 
tity of  contraction,  if  it  be  perceived  at  all,  produces  pain. 
These  constitute  sensation. 

A  certain  quantity  of  sensation  produces  desire,  or  aver- 
sion.    These  constitute  volition. 

All  animal  motions,  which  have  occurred  at  the  same  time, 
or  in  immediate  succession,  become  so  connected,  that,  when 

*  Zoonomia,  vol.  i.  p.  15. 

f  Ditto,  p.  33. 

t  Ditto. 

)'  Ditto,  p.  30. 


104 

one  of  them  is  reproduced,  the  other  has  a  tendency  to  ac- 
company or  succeed  it.  When  fibrous  contractions  succeed 
or  accompany  other  fibrous  contractions,  the  connexion  is 
termed  association  :  When  fibrous  contraction  succeeds 
sensorial  motions,  the  connexion  is  termed  causation  :  When 
fibrous  and  sensorial  motions  reciprocally  introduce  each 
other,  it  is  termed  catenation  of  animal  motion.  All  these 
connexions  are  said  to  be  produced  by  habit,  that  is,  by  fre- 
quent repetition.* 

The  spirit  of  animation  acts  in  four  different  ways,  or 
"  possesses  four  different  faculties  ;"f  and  the  contraction  of 
all  the  fibrous  parts  of  the  body  depends  upon  the  exertion 
of  these  powers.  The  property,  or  capability,  of  causing 
fibrous  contractions,  in  consequence  of  the  irritation  of  ex- 
ternal bodies,  is  called  irritability,  and  the  effect  irritation  ; 
which  is  defined  to  be  an  exertion,  or  change  of  some  ex- 
treme part  of  the  sensorium,  residing  in  the  muscles  or  or- 
gans of  sense,  in  consequence  of  the  appulses  of  external 
bodies. 

The  faculty  of  causing  fibrous  contractions,  in  consequence 
of  the  sensations  of  pleasure  and  pain,  is  termed  sensibility, 
and  the  effect  sensation ;  which  is  an  exertion,  or  change  of 
the  central  parts  of  the  sensorium,  or  of  the  whole  of  it, 
beginning  at  some  of  those  extreme  parts  of  it  which  reside 
in  the  muscles  or  organs  of  sense. 

The  power  of  causing  fibrous  contractions,  in  consequence 
of  volition,  is  called  voluntarity,  and  its  effect  volition  ; 
which  is  an  exertion,  or  change  of  the  central  parts  of  the 
sensorium,  or  of  the  whole  of  it,  terminating  in  some  of  these 
extreme  parts  of  it,  which  reside  in  the  muscles  or  organs  of 
sense. 

y  Zoonomia,  vol.  i.  p.  31  f  P  32. 


105 

The  capability  of  causing  fibrous  contractions,  in  conser 
quence  of  the  association  of  fibrous  contractions  with  other 
fibrous  contractions,  is  termed  associability,  and  the  effect 
association  ;  which  is  an  exertion,  or  change  of  some  extreme 
part  of  the  sensorium,  residing  in  the  muscles  or  organs  of 
sense,  in  consequence  of  some  antecedent,  or  attendant 
fibrous  contraction. 

As  these  faculties,  at  the  time  of  their  exertion,  may  be 
termed  motions  (for  we  cannot  pass  from  a  state  of  insen- 
sibility or  inaction  to  a  state  of  sensibility  or  exertion,  with- 
out some  change  in  the  sensorium,  and  every  change  includes 
motion,)  they  may  be  called  sensorial  motions. 

The  fibrous  motions  of  the  animal,  then,  are  of  four  differ- 
ent kinds,  irritative,  sensitive,  voluntary,  and  associate. 

In  every  contraction  of  a  fibre,  there  is  an  expenditure  of 
the  sensorial  power,  or  spirit  of  animation  ;  and,  when  the 
exertion  of  this  sensorial  power  has  been  for  some  time  in- 
creased, and  the  muscles,  or  organs  of  sense,  have,  in  conse- 
quence, acted  with  greater  energy,  there  is  an  exhaustion  of 
the  quantity  of  power :  On  the  contrary,  when  there  has 
been  less  exertion,  it  becomes  accumulated  in  the  inactive 
part.* 

Strength  is  the  consequence  of  the  presence  of  a  great 
quantity  of  stimulus  and  sensorial  power  ;  for  the  quantity  of 
motion  produced  in  any  particular  part  of  the  animal  system, 
will  be  as  the  quantity  of  stimulus,  and  the  quantity  of  sen- 
sorial power,  residing  in  contracting  fibres. 

If  the  quantity  of  sensorial  power  remain  the  same,  but 
the  quantity  of  stimulus  be  lessened,  then  debility  from  de- 
fect of  stimulus,  or  direct  debility,  of  Dr.  Brown,  is  pro- 
duced ;  in  which  case  the  contractions  are  feebler,  and  often 
retrograde. 


*  Zoonomia,  vol.  i.  p.  72. 
VOL.    I.  O 


106 

If  the  quantity  of  stimulus  remain  the  same,  but  the  quan- 
tity of  sensorial  power  be  lessened,  then  debility  from  defect 
of  sensorial  power,  is  produced,  or  indirect  debility.* 

Disease  is  the  consequence  of  any  deviation  of  these  mo- 
tions from  the  healthy  state  ;  and,  therefore,  are  divided  into 
diseases  of  irritation,  sensation,  volition,  and  association  ;f 
for  an  account  of  which,  as  well  as  of  the  minuter  parts  and 
illustrations  of  the  theory,  I  must  refer  to  the  work  itself. 

In  examining  the  truth  of  this  theory,  it  is  proper,  first,  to 
consider,  how  far  the  doctrine  of  simple  motions  will  explain 
the  phenomena  of  life  ;  and,  second,  how  far  their  derange- 
ment will  account  for  the  different  diseases.  It  would  be 
endless  to  follow  the  application  of  this  theory  through  the 
whole  animal  economy.  I  shall  deem  it  sufficient  to  attend 
only  to  one  or  two  functions,  particularly  digestion  and  se- 
cretion. 

The  whole  system,  says  Dr.  Darwin,  consists  of  extremi- 
ties of  nerves  ;  and  all  the  filaments  either  do  possess,  or  once 
possessed,  the  power  of  contraction.^  By  the  motion  of 
these  fibres,  are  all  the  operations  of  the  living  system,  and 
all  its  functions,  immediately  performed.  Now,  these  mo- 
tions can  only  consist  either  in  contraction  or  dilatation,  in 
various  directions.  This,  I  apprehend,  must  be  admitted ; 
and  no  other  kind  of  motion  is  proposed  by  Dr.  Darwin,  ex- 
cept sensorial  motions,  which  give  pleasure  and  pain.  The 
operation  of  sensation,  or  the  sensorial  motions,  is  indeed 
very  fully  admitted  in  this  theory,  and  supposed  to  regulate 
many  of  the  functions  ;||  but  still  these  must,  in  the  end, 


*  Zoonomia,  vol.  i.  p.  lb. 

f  P.  .361.  et  seq. 

t  Zoonomia,  vol.  i.  p.  463. 

||  "  If  the  food  which  we  swallow  is  not  attended  with  an  agreeable  sensation, 
it  digests  less  perfectly;  and,  if  a  very  disagreeable  sensation  accompanies  i;, 
such  as  a  nauseous  idea,  or  very  disgustful  taste,  the  digestion  becomes  impeded, 


107 

operate  upon  the  fibrous  contraction,  which  I  can  conceive 
only  to  admit  of  two  slates,  namely,  relaxation  and  contrac- 
tion. Now,  these  never  can  explain  the  varied  phenomena 
of  life,  and  all  its  intricate  and  peculiar  actions  ;  neither  can 
it  possibly  account  for  the  diseases  to  which  we  are  subject, 
even  although  we  admit  of  all  the  complications  of  motion 
which  Dr.  Darwin  supposes  to  exist. 

If  I  have  succeeded  in  establishing  the  doctrine  of  varied 
and  constant  actions,  in  the  living  system,  then  Dr.  Darwin's 
theory,  of  the  effects  of  simple  motions,  is  necessarily  un- 
founded; and  if  the  effects  of  actions  upon  the  body,  de- 
pend not  altogether  upon  their  quantity  or  degree,  but  also 
upon  their  species,  or  similarity  or  dissimilarity  to  the  na- 
tural action,  then  the  supposition  made  by  Dr.  Darwin  and 
Dr.  Brown,  that  the  expenditure  of  power  or  weakness,  is 
proportioned  exactly  to  the  quantity  of  exertion,  motion,  or 
excitement,  is  unfounded;  and  if  the  doctrine,  of  the  pro- 
duction of  energy  being  dependent  upon  the  due  presence  of 
action,  be  admitted,  the  supposition  of  the  accumulation  of 
excitability,  or  spirit  of  animation,  must  likewise  be  unsup- 
ported. 

Before  quitting  this  subject,  I  shall,  for  the  satisfaction  of 
the  reader,  take  notice  of  the  explanation  which  is  given 
of  fever.  ^ 


or  retrograde  motions  of  the  stomach  and  cesophagus,  succeed,  and  the  food  is 
ejected."    Zoonoraia,  vol.  i.  p.  390. — "  Every  kind  of  gland  must  possess  a  pecu- 
liar kind  of  irritability,  and,  probably,  sensibility,  at  the  early  state  of  its  exist 
ence,  and  must  be  furnished  with  a  nerve  of  sense,  or  of  motion,  to  perceive,  and  to 
select,  and  to  combine,  the  particles  which  compose  the  fluid  it  secretes."    P.  516. 
"  It  would  seem,  that  all  the  glands  in  the  body  have  their  secreted  fluids  affected, 
in  quantity  and  quality,  by  the  pleasurable  or  painful  sensations,  which  produced' 
accompany  those  secretions  ;  and  that  the  pleasurable  sensations,  arising  from 
these  secretions,  may  constitute  the  unnamed  pleasure  of  existence,  which  is  con 
trary  to  what  is  meant  by  tedium  vitae,  or  ennui."    P.  518. 
*  Zoonomia,  vol.  i.  p.  380.  et  seq. 


108 

When,  by  the  application  of  cold,  inanition,  fear,  &c.  a 
torpor,  or  quiescence,  of  any  considerable  part  of  the  circle 
of  irritative  motions,  is  induced,  the  whole  class  of  them  is 
more  or  less  disturbed,  by  their  irritative  associations  ;  or,  in 
other  words,  if  any  such  debilitating  cause  be  applied  to  a 
part,  the  rest  quickly  sympathises,  and  becomes  weakened. 
From  the  quiescence  of  the  particular  organs  concerned  in 
producing  the  various  functions,  we  have  diminution  of  these 
functions,  sickness,  vomiting,  paleness,  coldness,  weak  and 
small  pulse,  &c. 

But,  "  as  soon  as  this  general  quiescence  ceases,  either  by 
a  diminution  of  its  cause,  or  by  the  accumulation  of  sensorial 
power,  which  is  the  natural  consequence  of  previous  quies- 
cence, the  hot  fit  commences."  Every  gland  is  now  stimu- 
lated into  stronger  action  than  is  natural ;  there  is  a  supera- 
bundance of  all  the  secretions,  and,  in  consequence  of  this, 
an  increase  of  heat ;  the  skin  becomes  red,  and  the  perspira- 
tion great ;  but,  as  the  absorption  is  still  great,  the  sweat  is 
not  perceived,  until,  in  the  decline  of  the  hot  fit,  the  mouths 
of  the  absorbents  of  the  skin  are  exposed  to  the  cooler  air, 
or  bed-clothes,  by  which  they  lose  their  increased  activity, 
and  cease  to  absorb  more  than  is  natural  ;  but  the  secerning 
vessels  act  for  some  time  longer,  being  kept  warm  by  the 
circulating  blood  ;  and,  therefore,  we  have  a  sweating  stage. 

When  the  contractile  sides  of  the  heart  and  arteries  per- 
form a  greater  number  of  pulsations,  in  a  given  time,  and 
move  through  a  greater  area  at  each  pulsation,  whether  these 
motions  be  produced  by  the  acrimony  or  quantity  of  the 
blood,  or  by  association  with  other  irritative  motions,  or  in- 
creased sensorial  power,  or  by  any  stimulus,  we  have  synocha, 
or  irritative  fever,  with  strong  pulse.*  When,  again,  the 
contractile  sides  of  the  heart  and  arteries  perform  a  greater 

*  Zoonomia,  vol.  i.  p.  361. 


109 

number  of  pulsations,  in  a  given  time,  but  move  through  a 
less  area  at  each  pulsation,  from  defect  of  stimulus,  or  of  sen- 
sorial power,  we  have  typhus  mitior,  (or  nervous  fever,)  or 
irritative  fever,  with  weak  pulse.*  Besides  these  febrile  mo- 
tions, induced  by  irritation,  it  frequently  happens,  that  pain 
is  excited  by  the  violence  of  the  fibrous  contractions,  and 
other  new  motions  are  superadded,  in  consequence  of  sensa- 
tion. This,  which  occasions  inflammation,  gives  a  different 
form  to  the  fever,  which  is  called  sensitive,!  and,  like  the  ir- 
ritative fever,  will  naturally  be  of  two  kinds,  having  the  strong 
and  weak  pulse  ;  the  first  is  called  inflammatory  fever,  the 
second,  typhus  gravior.  This  is  farther  explained,  by  ob- 
serving, that,  when  the  motions  of  any  part  of  the  system,  in 
consequence  of  previous  torpor,  are  performed  with  more 
energy  than  in  the  irritative  fever,  (or  than  is  compatible 
with  the  existence  of  simple  irritative  fever,)  a  disagreeable 
sensation  is  produced,  and  new  actions,  of  some  part  of  the 
system,  commence,  in  consequence  of  this  sensation,  con- 
jointly with  the  irritation  ;  which  motions  constitute  inflam- 
mation ;  and,  according  as  this  has  taken  place,  in  one  or 
other  of  the  species  of  irritative  fever,  so  shall  we  have  either 
inflammatory  or  putrid  fever.  J. 

Upon  this  subject,  I  shall  only  remark,  that  the  general 
account  of  the  production  of  the  symptoms  of  fever,  is  not 
satisfactory,  and  that  the  causes  assigned  will  not  produce 
the  effect,  as  will,  I  presume,  sufficiently  appear,  from  what 
has  been  already  said  in  this  dissertation.  Cold,  applied  to 
the  system,  may  sometimes  produce  fever;  but,  upon  this 
supposition,  it  ought  uniformly  to  do  so,  which  is  not  the 
case ;  and  farther,  every  debilitating  cause,  as  venesection, 
poor  diet,  want  of  food,  &c.  ought  always  to  he  followed  by 


*  Zoonomia,  vol.  i.  p.  362. 
t  Ditto,  p.  301. 
J  Ditto,  p.  412. 


110 

paroxysms  of  fever,  in  consequence  of  the  quiescence  which 
they  induce.  There  is,  likewise,  no  proof,  lhat  sensation  af- 
fects the  nature  of  a  fever,  and  produces  local  inflammation ; 
but  there  is  very  abundant  evidence,  that  peculiar  agents, 
acting  on  the  living  system,  may  induce  fever,  and  modify 
the  action,  to  an  almost  endless  degree,  producing  the  whole 
tribe  of  febrile  diseases. 

Summary  of  the  Laws  of  Action. 

Having  made  these  observations  upon  the  different  systems 
of  pathology,  and  having,  in  the  course  of  this  dissertation, 
endeavoured  to  establish  the  necessity  of  attending  to  the 
actions  of  the  living  system,  and  of  ascribing  to  them  the 
phenomena  of  health  and  disease,  instead  of  indulging  in  spe- 
culations concerning  the  fluids,  or  their  changes,  or  about 
simple  excitement,  or  motions  of  the  system,  I  shall  now 
conclude  this  part  of  my  subject,  with  a  short  summary  and 
illustration  of  the  doctrine.     For  which  purpose,  I  observe, 

First.  That  the  nervous  energy,  unacted  on,  can  exhibit 
no  phenomena,  nor  perform  any  operations. 

Second.  Arterial  blood  seems  to  be  the  natural  and  indis- 
pensible  stimulus  to  this  nervous  system,  or  agent,  enabling 
the  energy  to  perform  its  operations.  It  is  likewise  the 
source  of  renewal  to  this  energy. 

Third.  In  a  state  of  health,  there  is  a  particular  action 
present  in  the  system,  upon  which  that  state  depends.  This 
may,  therefore,  be  called  the  natural  action,  and  consists,  col- 
lectively, of  all  the  operations  or  phenomena  necessary  for 
the  existence  of  the  animal. 

Fourth.  This  action  is  an  operation  of  the  nervous  energy, 
which  is,  therefore,  employed  and  expended  in  ils  perform- 
ance ;  on  which  account,  there  must  be  a  regular  renewal  of 


Ill 

power ;  and  this  renewal  is  dependent  upon  the  proper  ac- 
tion of  the  nerves.* 

Fifth.  All  external  agents,  or  foreign  bodies,  capable  of 
operating  on  the  body,  must  induce  an  action,  more  or  less 
different  from  the  natural  one  ;  or,  in  other  woids,  will  change 
the  action  of  the  system  to  a  greater  or  less  degree.  As  it 
is  certain,  that  no  two  actions  can  be  separately  performed  by 
the  same  part  at  once,  more  than  the  tongue  can  articulate 
two  languages  at  the  same  moment,  f  it  follows,  that  the  new 
action,  thus  induced  by  foreign  agents,  must  be  a  complica- 
tion of  the  new  action  with  the  natural  one;  or,  to  speak 
more  properly,  the  natural  action  becomes  modified  by  the 
new  stimulus ;  and  the  more  that  this  action  is  changed,  or 
becomes  diseased,  the  more  must  the  part  suffer.  From  ob- 
servation fourth,  it  will  appear,  that  the  production  of  energy 
must  be  thus  injured  ;  and  it  will  be  at  once  evident,  that  if 
health  and  strength  consists  in  the  due  existence  and  per- 
formance of  the  natural  action,  if  this  action  be  changed, 
weakness  and  disease  must  be  the  consequence  ;  and,  like- 
wise, that  these  diseases  are  most  dangerous  in  which  the  ac- 
tion is  greatly  changed  ;  whereas,  in  these  in  which  it  is  less 
altered,  the  danger  is  less,  and  they  may  subsist  longer  with- 
out producing  death. 

Sixth.  It  is  necessary,  that  every  new  agent,  or  stimulus, 
should  have  a  certain  degree  of  strength  ;  or,  in  other  words. 


*In  some  diseases,  we  find,  that  the  nerves  do  not  take  from  the  blood  as  much 
life  as  it  is  capable  of  yielding.  In  this  case,  the  blood  in  the  veins  is  redder  than 
usual,  and,  when  drawn,  coagulates,  almost  totally,  into  a  mass,  containing,  like 
j  lie  coagulum  of  arterial  blood,  the  greatest  quantity  of  the  serum,  blended  with 
the  other  principles.  In  many  diseases,  proceeding  from  derangement  of  the 
stomach  and  bowels,  and  in  approaching  syncope,  this  fact  may  be  observed. 

f  Although  no  two  actions  can  exist  separately  in  the  same  place,  and  at  the 
<ame  time,  yet  they  may  sometimes  become  blended,  producing  an  action  differ- 
ent from  either.  Some  actions,  however,  cannot  be.  thus  blended,  but  the  one  wiii 
displace  the  other,  or  will  not  tnk^  place  at  all 


112 

possess  a  certain  quantity  of  the  peculiar  power  by  which  it 
operates,  in  order  to  act  upon  the  living  system ;  because  the 
natural  action,  if  I  may  use  the  expression,  keeps  its  ground, 
with  a  certain  degree  of  tenacity,  and  will  only  yield  to  a 
certain  force.  For  example,  a  grain  of  ipecacuanha,  a  drachm 
of  glauber  salt,  a  drop  of  laudanum,  or  contagious  matter, 
much  diluted,  will  produce  no  effect  upon  a  man.  Were 
this  not  the  case,  we  never  should  enjoy  health  ;  because  the 
small  quantity  of  contagious  matter,  which  we  may  suppose 
to  be  often  contained  in  the  air,  should  uniformly  affect  us. 
The  less  energy  that  a  person  has,  the  weaker  is  the  natural 
action  ;  and,  the  weaker  that  the  natural  action  is,  the  easier 
is  it  changed,  or  destroyed.  Hence,  the  child  is  more  easily 
injured  than  the  adult ;  and  he  who  is  reduced  by  fatigue, 
abstinence,  or  previous  disease,  than  the  healthy  and  robust 
man.  This  law  likewise  obtains,  with  regard  to  the  actions 
of  sense,  as  every  one  knows  who  has  attended  to  the  phe- 
nomena of  seeing,  hearing,  tasting,  Sec. 

Seventh.  Certain  agents,  which  may  have  strength  enough 
(by  which  I  mean  capability)  to  change  the  natural  action, 
will  not  be  sufficient  to  affect  it,  if  it  has  already  been  modi- 
fied by  the  previous  application  of  a  different  agent.  It  is 
on  this  account  that  contagions  often  fail,  at  particular  times, 
to  produce  their  effect :  Because  the  presence  of  some  other 
agent  has  previously  modified  the  action,  more  or  less ;  and, 
until  the  effects  of  this  be  gone  off,  no  new  disease  takes 
place,  unless  the  new  stimulus  be  very  dissimilar  indeed  to 
that  which  induced  it.  We  have  an  instance  of  the  one 
case,  in  small-pox  not  displacing  measles  ;  of  the  second,  in 
mercury  destroying  the  venereal  action. 

Eighth.  The  agent  in  general  operates  most  on  the  part 
to  which  it  is  immediately  applied,  if  that  part  be  susceptible 
of  its  operation,  and  in  a  less  degree  upon  neighbouring  parts. 
The  degree,  however,  to  which  these  agents  may  extend 


113 

their  action,  is  very  various.  Some,  for  instance,  when 
taken  into  the  stomach,  extend  their  action  over  the  whole 
system,  whilst  others  act  only  upon  the  stomach  itself,  and 
produce  no  effect  on  the  rest  of  the  body,  except  such  as 
take  place  in  consequence  of  the  sympathy  of  equilibrium. 
When  heat  is  applied  to  a  part,  it  inflames  that  part, 
but  acts  likewise,  in  a  less  degree,  on  those  which  are 
near  it ;  so  that  if  one  spot,  to  which  most  heat  was  ap- 
plied, mortifies,  or  forms  an  eschar,  those  near  it  shall  only 
exhibit  a  moderate  degree  of  inflammation.  Cantharides 
likewise  extend  their  action  beyond  the  spot  to  which  they 
are  applied,  but  in  a  much  less  degree  than  heat.  Conta- 
gions, however,  producing  specific  inflammation,  are  more 
confined  in  their  operation  than  simple  inflaming  causes. 
Specific  inflammation  generally  terminates  more  abruptly  5 
that  is  to  say,  it  does  not  diffuse  itself  so  far  as  simple  in- 
flammation ;  but  sometimes  it  is  surrounded  by  simple  in- 
flammation. Thus  the  variolous  inflammation  is  surrounded 
by  a  simple  erysipelatous  inflammation. 

Ninth.  The  impressing  cause,  or  stimulus,  must  not  only 
be  of  a  certain  strength,  but  it  must  also  be  applied  for  a  cer- 
tain length  of  time  before  it  can  produce  its  effect.  That: 
some  time  is  necessary  for  the  formation  of  an  action  is  evi- 
dent ;  because,  setting  all  other  reasons  aside,  we  observe  a 
certain  interval  betwixt  the  first  derangement  of  the  natural 
action  and  the  appearance  of  the  new  action,  in  its  full  and 
proper  state.  This  period  of  formation  is  always  marked  by 
symptoms  of  weakness,  such  as  lassitude  and  chilliness ;  and 
the  effects  of  impaired  functions,  such  as  anorexia,  thirst, 
and  head-ache,  even  although  the  action,  when  fully  formed, 
should  be  such  as  to  require  bleeding,  and  what  are  called 
sedatives,  as  we  see  illustrated  by  the  history  of  inflamma- 
tion. These  symptoms  do  not  precede  those  actions  alone 
which  are  called  diseased  ;  for  we  find  similar  effects  pro* 

vol.  1.  r 


114 

duced  during  the  formation  of  those  actions  which  are  after- 
wards to  become  permanent  and  natural.  Thus  the  child 
during  dentition,  the  young  animal  during  the  shooting  foth 
of  his  horns,  the  peacock  when  he  gets  his  crest,  and  the 
turkey  when  the  fleshy  excrescences  on  the  head  are  formed, 
have  all  a  diminution  and  affection  of  the  natural  action,  pro- 
ducing disorder  of  the  system,  and  sometimes  even  death 
itself.  The  time  which  is  required  for  the  formation  of  these 
actions  is  various  ;  nor  can  the  exact  duration,  in  evcy  in- 
stance, be  easily  ascertained.  It  may,  however,  be  observ- 
ed, in  general,  that  the  more  dissimilar  the  new  action  is  to 
the  old  or  natural  one,  and,  consequently,  the  more  danger- 
ous that  it  is,  the  sooner  is  it  formed  j*  but  as  many  causes 
(particularly  the  previous  existence  of  other  actions,  or  mo- 
difications of  the  natural  action,  although  so  slight  as  not  to 
be  much  attended  to)  may  tend  to  interrupt  and  postpone 
the  establishment  of  the  action,  the  period  of  formation  in 
the  same  action  may  be  different  at  different  times.  And, 
farther,  as  the  constitution  or  natural  action  of  no  two  peo- 
ple are  exactly  alike,  the  time  of  formation  will  vary  in  dif- 
ferent people ;  and,  in  some,  particular  actions  may  never,  or 
very  seldom  take  place,  although  they  be  fully  exposed  to 
the  exciting  cause. f 

But  besides  this  time  which  elapses  during  the  formation 
of  an  action  before  it  fully  appears,  there  is  likewise  an  in- 
terval betwixt  the  application  of  the  cause  and  the  com- 
mencement of  the  formation;  but  this  is  much  less  in  some 
diseases  than  in  others.  It  is  natural,  however,  to  suppose, 
that  this  interval  bears  some  proportion  to  the  quickness  of 
the  formation.      The  coniagion  of  very  bad  typhus  fevers, 

*  The  fevers,  vulgarly  called  putrid,  that  is,  very  bad  fevers,  come  on  with  a 
shorter  cold  fit  than  those  which  are  milder.  The  position  is  likewise  illustrated 
by  many  other  diseases. 

f  Some  neople  n  re  much  less  subject  to  fevers,  to  .syphilis,  &c.  than  others ;  and 
'Some  never  take  the  small-pox. 


115 

for  instance,  operates  much  sooner  than  that  of  the  common 
ne  vous  fever,  as  it  is  called. 

A  knowledge  of  the  different  times  required,  by  certain 
agents,  to  produce  these  effects,  is  of  no  small  importance, 
be  ause  we  may  thus  be  able  to  escape  their  action,  in  many 
cases.  By  washing  off  some  contagions  shortly  after  their 
application,  we  prevent  the  disease,  as  we  see  illustrated  by 
syphilis.  In  cases  whe.e  poisons  a;e  taken  into  the  stomach, 
we  can  prescribe  an  emetic,  which  operates  more  qui  kly, 
and  thus  removes  them ;  and  for  this  pU)  pose,  we  employ 
white  vitriol  rather  than  emetic  tartar,  because  the  one  acts 
more  speedily  Shan  the  other. 

Tenth.  The  same  siimulus  will  always  produce  actions  ra- 
dically the  same  ;  but  varying  the  degree  of  stimulus  will 
of: en  so  affect  the  action,  as  to  make  it  apparently  different. 
Thus,  heat,  in  a  small  degree,  makes  the  natural  action  be 
carried  on  more  perfectly,  and  gives  pleasure;  but,  in  a 
greater  degree,  it  increases  the  action  so  much,  as  to  change 
its  appearance,  or  visible  effects  and  symptoms,  producing  in- 
flammation, which,  from  analysis,  we  learn  to  be  an  increase 
of  .he  natural  action. 

Eleventh.  The  action  remains  for  some  time  after  the 
agent  is  withdrawn.  If  this  were  not  the  case,  we  should  al- 
ways be  able  to  cure  a  disease,  by  removing  the  exciting 
cause,  which  no  one  expects  to  be  able  to  do.  Removing  a 
blistering  plaster,  for  instance,  will  not  immediately  remove 
the  inflammation  which  it  has  produced.  There  is,  however, 
no  certain  rule  for  the  duration  of  these  actions ;  because  one 
continues  much  longer  than  another  ;  and  some  seem  even  to 
have  no  tendency  to  decrease  or  disappear  after  any  dura- 
tion, however  long.* 

*  It  is  impossible,  in  the  present  state  of  our  knowledge,  to  ascertain  the  im- 
mediate cause  of  this.  We  cannot,  for  instance,  say  why  the  variolous  inflam- 
mation subsides  spontaneously  in  a  few  days,  whiht  the  venereal  action  remain* 


116 

Twelfth.  All  actions  affect  one  part  of  the  body  more 
than  the  rest.  Sometimes  there  is  only  one  organ  affected, 
producing  a  disease  entirely  local ;  at  other  times,  the  whole 
system  suffers  ;  but,  in  this  case,  there  is  always  one  part  in 
which  the  action  chiefly  exists. 

All  morbid  actions,  which  are  extended  over  the  system, 
aflect  the  circulation,  and  produce  frequency  of  pulse ;  and, 
when  fully  formed,  heat  of  the  skin.  These,  when  concen- 
trated in  any  part,  or  when  they  affect  any  organ  to  a  great 
degree,  produce  a  species  of  inflammation ;  and  it  is  easy, 
from  the  connexion  of  the  inflammatory  action  with  the  state 
of  the  vessels,  to  see  how  this  should  take  place.  If  the  ac- 
tion exists  to  less  degree  than  this  in  the  part,  then  it  does 
not  produce  inflammation,  but  only  pain,  and  a  state  border- 
ing on  inflammation. 

Thirteenth.  When  specific  inflammation  is  induced  in  any 
part,  the  susceptibility  of  the  neighbouring  parts,  for  assum- 
ing this,  is  lessened ;  and  they  seldom  do  assume  it,  unless 
some  stimulant  be  applied  to  them.  Thus,  a  certain  number 
of  pustules  are  produced  in  small-pox,  by  which  the  rest  of 
the  surface  is  less  subject  to  the  variolous  inflammation.  If, 
however,  other  stimulants  be  applied,  such  as  heat,  then,  not- 
withstanding the  diminished  susceptibility,  the  inflammation 
is  excited,  and  a  great  eruption  is  produced. 

Fourteenth.  Those  agents  which  induce  actions  nearly  si- 
milar to  the  natural  one,  or  which  change  its  nature  little,  at 
least  comparatively  speaking,  may  be  called  agentes  similes  : 
These,  which  have  also  been  named  stimulants,  uniformly 
produce  weakness,  after  their  operation  is  over,  unless  it  sub- 
side very  slowly,  and  thus  allow  the  natural  action  gradually 
to  regain  its  perfection  before  their  artificial  action  disap- 


unabated  through  life ;  neither  can  we  tell  why  the  action  induced  by  opium 
subsides  in  a  few  hours,  whilst  that  of  typhus  continues  for  days ;  why  some  ac- 
tions disappear  and  return  alternately,  for  a  length  of  time,  and  others  remain 
constantly  the  same. 


117 

pears,  and,  consequently,  before  the  system  can  be  reduced 
to  an  inactive  condition,  as  we  see  in  the  effects  of  great  and 
sudden  muscular  exertions,  which  weaken  more  than  a  long 
continued,  but  gentler  action,  though  this,  in  the  sum,  be 
greater  than  the  other. 

As  these  actions  resemble,  in  some  degree,  the  natural  ac- 
tion, they  also,  in  some  degree,  supply  its  place  ;  and  we  often 
do  not  so  readily,  during  their  continuance,  perceive  the  weak- 
ness which  they  induce ;  but,  at  other  times,  we  can  readily 
detect  its  existence,  at  least  in  particular  functions.  Thus, 
for  instance,  the  presence  of  inflammation  uniformly  impairs 
the  function  of  the  inflamed  part,  as  we  see  in  the  case  of 
muscular  motion,  which  is  diminished  in  rheumatism  ;  for,  in- 
dependent of  the  pain,  we  could  not  make  the  same  exertion 
as  formerly ;  and,  in  synocha,  we  cannot  walk,  nor  eat,  nor  do 
what  we  used  to  do.  If,  however,  the  action  be  still  more 
nearly  resembling  the  natural  action ;  or,  if  the  nature  of  the 
healthy  action  be  still  less  changed,  then  we  do  not  perceive 
the  weakness  as  long  as  it  continues,  as  we  see  in  the  case  of 
the  vinous  action  ;  on  the  contrary,  the  person  can  make  a 
greater  exertion  during  it,  because  it  differs  very  little  from 
the  natural  action.* 

When  the  action  of  any  part  is  much  increased,  its  power 
is  expended  ;  and,  therefore,  in  order  to  prevent  farther 
weakness,  after  the  operation  of  the  stimulant  is  over,  we 
find,  that  the  action  of  the  system  is  diminished  in  propor- 
tion to  the  diminished  power,  and  both  are  only  slowly  in- 
creased or  renewed.     This  fact  is  overlooked  by  the  Brown- 


*  According  to  the  Brownonian  doctrine,  stimulant  actions  should  not  produce 
weakness  until  their  operation  be  over.  But  experience  proves,  that  the  reverse- 
is  the  case ;  and  I  have  endeavoured  to  show  why  it  does  not  appear  in  every 
period  of  an  action,  and  in  which  actions  we  are  to  expect  it  We  do  not  observe 
it  in  the  vinous  action,  if  it  exist  only  in  a  slight  degree;  but  if  it  be  greater,  it 
becomes  evident.  We  observe  it  uniformly  in  inflammatory  diseases,  and,  in- 
deed, during  the  contiuuance  of  every  stimulant  action,  if  it  be  induced  to  a  con- 
•idtrable  degree. 


118 

onians,  who  give  stimulants  in  this  case,  as  they  say,  to  in- 
crease the  excitement.  But  this  practice  is  evidently  im- 
proper, in  most  cases  ;  and,  where  it  is  admissible,  the  quan- 
tity of  stimulus  must  be  very  small,  and  must  be  of  such  a 
kind  as  tends  to  excite  the  natural  action  of  the  part ;  as,  for 
instance,  soups  for  the  stomach,  &c. 

The  more  quickly  that  the  stimulant  action  is  induced,  and 
the  greater  its  degree,  the  more  quickly  does  the  weakness 
appear,  and  the  greater  is  it.  This  evidently  must  be  the 
case;  because  action  requires  power  or  energy;*  and  the 
more  quickly  that  it  is  raised,  the  less  able  is  the  nerve  to 
supply  this  energy.f  When  a  part  is  scalded  with  water, 
there  is  a  very  great  action  instantaneously  induced  ;  and, 
therefore,  there  is  a  weakness  of  the  part  very  quickly  in- 
duced;  and  the  inflammation  requires  the  application  of 
gentle  stimulants  for  its  cure,  as  will  be  afterwards  mention- 
ed. If  the  'degree  of  heat  has  been  still  greater,  then  im- 
mediate death,  or  mortification  of  the  part,  takes  place,  and 
an  eschar  is  formed. 

From  these  remarks,  it  is  evident,  then,  that  increased  ac- 
tion, in  consequence  of  the  application  of  stimulants  pro- 
ducing diseases,  as  well  as  an  increased  exercise  of  particu- 
lar functions,  will  produce  weakness,  which  will  be  sensibly 
perceived,  unless  the  stimulant  action  very  nearly  resembles* 
the  natural  one,  and  subsides  very  gradually.  The  vinous 
action,  unless  it  has  been  moderate,  and,  consequently,  les- 
sens gradually,  produces  weakness ;  muscular  exertion  fa- 
tigues ;  too  much  food  taken  into  the  stomach  weakens  it, 
and  vomiting,  or  temporary  dyspepsia,  take  place  ;  heat  over- 
powers the  system,  and  causes  fainting. 


*  It  is  easy,  from  this,  to  see  how  weakened  parts  should  bear  disease  worse 
than  the  strong. 

f  One  cause  of  this,  amongst  many  others,  is,  that  the  more  abrupt  the  transi- 
tion is,  from  one  state  to  another,  the  more  is  the  function  injured. 


119 

Fifteenth.  Those  agents  which  induce  actions  very  dissi- 
milar to  the  natural  action,  may  be  called  dissimiles,  and  pro- 
duce great  weakness  very  quickly ;  whereas,  in  many  instan- 
ces of  stimulant  actions,  when  they  do  not  arise  to  a  great  de- 
gree, the  sensible  weakness  is  not  perceived  for  a  considera- 
ble time,  and  until  ihe  stimulant  action  has  subsided. 

The  agentes  dissimiles,  or  what  have  been  improperly  call- 
ed sedatives,  may,  like  the  agentes  similes,  or  stimulants,  in- 
due  very  violent  actions,  and  will  often  require  the  use  or 
such  remedies  as  tend  to  abate  action  in  general ;  such  as 
cold  and  blood-letting.  These  actions  are  always  attended 
with  an  inflammatory  affection,  when  they  exist,  in  a  great 
degree,  in  any  organ.  That  typhus  is  always  attended  with 
an  inflammatory  affection  of  the  head,  and  sometimes  of  the 
lungs,  or  abdominal  viscera,  must  be  acknowledged  by  every 
one,  who  is  conversant  in  dissection  :  that  the  plague  and  yel- 
low fever  are  attended  with  inflammation,  is  equally  certain ; 
that  lead  induces  inflammation,  is  so  well  known,  that  bleed- 
ing is  frequently  used,  with  success,  in  the  cholic  which  it 
produces :  laurel  water  produces  an  inflammatory  or  haemorr- 
hagic  action  of  the  brain,  marked  frequently  by  delirium,  red 
eyes,  and  turgidity  of  the  vessels.  It  must,  therefore,  ap- 
pear, that  the  medicines,  called  sedatives,  have  no  title  to 
that  appellation,  which  belongs  only  to  such  agents  as  tend  to 
abate  action  in  general ;  and,  therefore,  can  only  be  properly 
applied  to  venesection,  and  cold,  and  abstinence,  which,  un- 
der certain  circumstances,  abate  action,  not  indeed  by  any 
positive  power,  or  peculiar  quality,  but  negatively,  by  remov- 
ing causes,  which  keep  up  action. 

Notwithstanding  the  utility  of  bleeding,  in  the  beginning  of 
many  actions  belonging  to  this  class,  it  yet  must  be  remem- 
bejed,  that  the  practice  is  hurtful,  if  employed  too  late,  and 
after  any  very  considerable  weakness  is  induced,  by  the  con- 
tinuance of  the  dissiinUar  action  :  opposite  remedies  will  then 
be  of  use. 


120 

The  actions  belonging  to  this  class  are  by  much  the  most 
dangerous,  as  will  appear  from  one  or  two  examples. 

When  a  person  is  bit  by  a  serpent,  we  invariably  find  very 
great  weakness  produced,  with  more  or  less  rapidity.  The 
countenance  becomes  pale,  a  tremor  seizes  the  whole  body, 
the  breathing  becomes  hurried  and  oppressed,  and  the  pulse 
weak  and  irregular  :  convulsions  close  the  scene.  These  are 
the  general  effects  of  the  bite  of  venomous  animals ;  but  we 
find  different  modifications  taking  place,  according  to  the 
specific  difference  of  the  poison.  The  bite  of  some  serpents 
is  fatal  in  less  than  an  hour,  whilst  that  of  others  does  not 
kill  for  a  much  longer  time.  Some  produce  violent  convul- 
sions, others  a  stupor  ;  some  cause  excruciating  pain,  whilst 
others  kill  with  an  easy  insensibility. 

The  poison  generated  by  rabid  animals,  is  likewise  a  very 
powerful  agens  dissimilis,  producing  great  languor  and  dejec- 
tion, and  weakness  of  all  the  functions,  attended  with  spasmo- 
dic affections  of  the  muscles,  and  particularly  of  those  of  the 
throat,  which  become  convulsed,  from  very  slight  causes. 

The  dissimilar  agent,  however,  which  we  most  frequently 
meet  with,  is  the  contagion  of  typhus  fever,  concerning  the 
nature  and  operation  of  which  there  have  been  many  disputes. 
Some  have  considered  the  putrefaction  of  animal  and  vegeta- 
ble matters  as  the  cause  producing  contagion  ;  others  have 
referred  it  to  an  unknown  state  of  the  air  ;  others,  to  certaia 
alterations  in  the  atmosphere,  which  might  be  ascertained  and 
imitated  by  chemical  processes ;  whilst  some  have  denied 
altogether  the  existence  of  typhus  contagion.  There  have 
been  still  more  disputes  about  the  nature  of  the  disease,  which 
this  contagion  induced.  Some  called  it  the  effect  of  fermen- 
tation; others,  of  spasm  ;  others,  of  pure  weakness  ;  but  the 
wisest  part  of  physicians  allow  it  to  be  a  peculiar  action,  which 
they  cannot  imitate  or  produce,  by  any  of  those  general 
causes. 


121 

As  all  these  agents  produce  great  weakness,  it  might  be 
supposed,  that  the  cure  ought  to  consist  entirely  in  prescrib- 
ing, from  the  very  first,  such  medicines  as  would  lend  to  pro- 
duce an  action  as  nearly  similar  to  the  natural  one  as  possi- 
ble ;  such  as  wine,  or  other  fermented  liquors.  But  it  is  to 
be  remembered,  that,  in  the  first  place,  those  actions  will  not, 
in  the  beginning,  yield  to  the  natural  one :  they  have  already 
destroyed  it  ;  and,  therefore,  it  is  not  to  be  expected,  that 
such  agents,  as  tend  only  to  excite  an  action  somewhat  simi- 
lar to  the  natural  one,  should  be  capable  of  displacing  these. 

There  is,  hoAvever,  a  still  more  serious  objection  to  this 
practice:  the  proposal  is  made,  without  attending  to  the  cir- 
cumstance of,  what  are  called,  sedative  actions,  being,  in  their 
commencement,  sometimes  so  violent, *  as  to  require  the  ap- 
plication of  such  causes  as  tend,  in  general,  to  abate  all  ac- 
tions indiscriminately ;  such  as  bleeding,  and  the  use  of  cold, 
to  a  moderate  degree.  It  is  likewise  to  be  observed,  that  as 
wine  cannot  displace  the  typhus  action  at  first,  it  will,  by  its 
operation,  tend  to  increase  it ;  and  as  bolh  the  contagion  and 
the  wine  act  more  upon  the  head  than  on  other  parts,  in  pro- 
portion to  their  size,  it  will  readily  be  seen,  why  the  early  use 
of  wine,  in  fevers,  so  frequently  produces  phrenitis  ;  for  it  has 
been  already  mentioned,  that  whenever  any  action  was  much 
increased,  or  concentrated  in  a  particular  part,  it  induced  a 
species  of  inflammation.  Wine,  however,  is  useful,  after  the 
first  stage  of  the  disease  is  over,  and  the  more  immediate  vio- 
lence of  the  action  has  subsided,  and  the  weakness  is  making 
progress  against  us.  In  this  case,  it  is  as  useful,  as  it  formerly 
was  hurtful. 


*  There  is,  in  the  beginning  of  these  actions,  a  state  somewhat  approaching  to 
i he  condition  in  inflammation ;  and  this  state,  of  violent  or  increased  action,  con- 
tinues longer  or  shorter,  in  different  sedative  actions.     In  some,  it  lasts  only  a 
few  hours,  and  the?e  are  the  most  dangerous. 
VOL.    I.  Q 


122 

Sixteenth.  Removing  the  sensible  effects  of  any  particu- 
lar action,  has  a  tendency  to  destroy  the  action  itself.  Thus, 
such  applications  as  abate  the  pain  of  the  head,  in  typhus  fe- 
ver, tend  to  abate  the  fever ;  such  as  abate  the  heat  in  inflam- 
mation or  fever,  abate  these  diseases.  This  is  called  practis- 
ing according  to  symptoms,  and  is  a  method,  at  all  times,  to  be 
followed,  even  in  the  cure  of  those  actions  or  diseases,  for 
which  we  possess  specific  remedies,  as  the  operation  of  those 
remedies  will  be  greatly  assisted  by  it. 

Seventeenth.  Diseases  are  often  cured  also,  by  removing 
the  particular  state  of  the  system,  which  gives  to  them  their 
peculiar  inveteracy  or  danger.*  Thus,  inflammation  of  weak- 
ened parts  is  removed,  by  strengthening  the  part ;  that  is  to 
say,  increasing  its  energy ;  which  we  do,  by  such  remedies 
as  act  on  the  whole  system,  at  the  same  time  that  we  apply 
such  agents  to  the  part  itself,  as  shall  tend  to  change  the  ac- 
tion. It  may  be  thought,  that  increasing  the  action  of  the 
system,  in  this  species  of  inflammation,  should  be  prejudicial, 
and  should  increase  the  inflammatory  action ;  because  this 
was  perhaps  originally  produced  by  the  communication  of  ac- 
tion from  the  neighbouring  parts  :  but  the  remedies  which  we 
employ,  tend  not  to  induce  an  inflammatory  action  in  those 
parts,  but  one  more  nearly  resembling  the  natural  action,  and 
thus  augment  the  energy,  and  diminish  the  inflammation.  If, 
however,  the  inflammation  has  happened  from  a  morbid  in- 
crease of  action,  in  a  part  already  strong,  then  such  remedies 
as  tend  to  increase  this  shall  do  harm. 

Eighteenth.  Actions  which  are  suddenly  induced,  in  heal- 
thy parts,  are  more  dangerous  than  those  which  are  excited 
mo;  e  gradually ;  or,  in  other  words,  the  more  speedy  the  tran- 
sition is,  from  healJi  to  disease,  the  more  does  the  animal  suf- 


*  Disease  is  often  so  connected  with  the  state  of  the  system  in  which  it  occur?, 
".Mt  removing  that  state  of  the  system,  shall  remove  the  disease 


123 

fer.  It  is,  for  instance,  observed,  that  people  bear  amputa- 
tion better,  if  it  be  performed  on  account  of  some  disease  of 
long  standing,  than  if  we  operate  on  account  of  some  sudden 
acsident;  one  cause  of  which  is,  that  the  constitution  had 
formerly  been  accustomed  to  a  diseased  state,  or  inflammatory 
action ;  and,  therefore,  suffers  less  by  the  one  which  our  ope- 
ration induces. 

Nineteenth.  The  more  the  system,  at  the  time  of  the  ap- 
plication of  any  new  ageut,  approaches  to  the  general  condi- 
tion which  that  agent  tends  to  induce,  the  more  dangerous  will 
the  action  of  the  agent  be,  and  the  more  readily  will  it  ope- 
rate. Thus,  typhus  fever  tends  to  produce  great  weakness, 
and,  therefore,  will  be  more  dangerous  when  it  attacks  those 
who  have  been  formerly  much  reduced  than  tho3e  who  have 
Hot.  Those,  again,  who  are  very  vigorous,  may  be  said,  as 
Mr.  Hunter  observes,  to  have  their  action  as  high  as  it  can  be 
without  disease  being  induced ;  very  trifling  causes  may, 
therefore,  operate  on  them.  Inflammation  will  be  very  high 
in  them ;  and  wounds,  or  accidents,  extremely  dangerous. 
They  will  even  be  more  easily  acted  on  by  the  agentes  dissi- 
miles,  or  sedatives,  as  they  have  been  called,  than  those  whose 
action  is  less,  and  nearer  the  proper  medium,  because  they 
are  more  easily  rendered  diseased,  and  the  inflammatory  state 
which  these  agents  tend  to  excite  will  be  more  violent  in 
them. 

Twentieth.  Contiguous  parts  sympathise  with  each  other 
to  a  certain  degree.  Hence,  if  the  action  of  any  part  be  in- 
creased, the  increase  spreads  in  a  less  degree  to  the  neighbour- 
ing parts,  unless  these  parts  exhibit  the  sympathy  of  equili- 
brium ;  such  as  the  skin  and  liver,  for  instance.  Hence  also, 
if  a  part  be  weakened  by  cold,  the  action  of  the  neighbouring 
parts  spreads  to  it  after  the  cold  is  withdrawn,  and  communi- 
cates to  it  a  greater  degree  of  action  ihan  its  weakened  state 
can  bear ;  the  consequence  of  which  is  inflammation,  which 


124 


ends  frequently  in  gangrene.  Upon  the  same  principle,  a  part 
draws  support  from  the  contiguous  parts,  and  bears  disease 
fflnii  longer,  on  this  account,  than  it  otherwise  would  do. 
Hence,  when  causes  act  locally  on  a  part,  in  such  a  way  as  to 
kill  it,  the  neighbouring  parts  are  weakened  ;  or,  if  it  be  a  large 
part  which  is  affected,  the  whole  system  is  injured. 

Twenty-first.  When  an  increased  action  is  induced  in  one 
part,  it  has  a  tendency  either  to  diminish  action  in  some  other 
part,  or  to  increase  it  for  a  time  in  that  part,  according  to  cir- 
cumstances, which  have  been  already  explained  in  treating  of 
the  sympathy  of  association,  and  the  sympathy  of  equilibrium. 
Contiguous  parts,  of  a  similar  structure,  most  frequently  ex- 
hibit the  sympathy  of  association,  and  the  action  spreads 
more  rapidly  in  them ;  contiguous  parts,  of  dissimilar  struc- 
ture, exhibit,  in  the  same  circumstances,  most  frequently,  the 
sympathy  of  equilibrium.  It  is  evident,  therefore,  why  all 
local  actions  extend  themselves  farthest,  and  most  quickly  in 
those  parts  which  are  similar  to  the  spot  in  which  they  com- 
menced. Hence,  as  Mr.  Hunter  has  observed,  when  one 
portion  of  a  gland  becomes  inflamed,  the  rest  also  becomes 
quickly  inflamed ;  but  the  surrounding  cellular  substance,  or 
skin,  is  much  longer  of  becoming  affected.  Hence,  also,  we 
may  sometimes  check  the  progress  of  some  cutaneous  actions, 
by  applying  caustic  round  the  diseased  spot,  so  as  to  enclose 
it  as  with  a  ring ;  for  the  nioibid  action  does  not  extend  itself 
deeper  than  the  skin,  and  it  does  not  overleap  the  destroyed 
or  altered  substance  produced  by  the  caustic ;  it  is  therefore 
checked. 

Twenty-second.  Contagious  matter,  generated  by  animals, 
has  a  greater  tendency  to  affect  animals  of  the  same  species 
win  h  produced  it,  than  others  ;  and  the  same  parts  in  another 
individual  which  have  produced  or  secreted  it  in  one,  rather 
than  parts  of  a  different  nature.  Thus,  the  contagious  matter 
produced  by  the  glands  of  the  urethra  in  gonorrhoea,  has  a 


125 

greater  tendency  to  affect  other  secreting  parts,  than  parte 
whi>  h  do  not  secreie. 

Twenty-:  hird.  Whenever  an  accustomed  stimulus  is 
withdrawn  from  a  part,  or  the  whole,  the  action  becomes  im- 
perfect and  irregular,  because  an  agent  which  was  wont  to 
contribute  to  its  production  is  absent.  This  produces  pain; 
for  all  new  and  irregular  actions  excite  disagreeable  sensa- 
tions. 

Twenty-fourth.  The  mind  has  the  capability  of  perceiv- 
ing and  taking  cognisance  of  the  actions  of  the  body ;  but  if 
these  actions  be  constantly  repeated,  we  at  last  do  not  perceive 
them,  or  receive  any  sensation.  Thus,  we  have  no  sensation 
from  the  performance  of  all  the  healthy  functions,  or  parts  of 
the  natural  action  :  or  from  the  mo  lion  of  the  heart  and  arte- 
ries. But  if  the  action  be  either  imperfect,  or  in  any  respect 
new,  then  it  produces  a  sensation,  which,  if  violent,  we  call 
pain.*  If  the  heart  contracts  irregularly,  or  in  a  different 
manner  from  what  it  formerly  did,  then  we  feel  it,  and  call  it 
palpitation.  All  new  general  actions  are  attended  with  an  in- 
describable uneasiness.  When  an  ulcer  is  painful,  we  may 
be  certain  that  the  healing  action  is  not  going  on ;  and,  ac- 
cording to  observation  sixteenth,  we  may  often  cure  it  by 
such  remedies  as  tend  to  abate  the  pain. 

Twenty-fifth.  Some  actions  are  continued  by  habit  alone. 
Any  action  which  has  continued  long  becomes  in  a  manner 
natural,  that  is,  excited  and  supported  by  the  natural  agents 
which  were  operating  when  it  was  first  induced,  and  dur- 
ing the  continuance  which  the  action  necessarily  had  on  ac- 
count of  the  strong  action  of  the   original    exciting  cause. 


*  We  are  not  always  to  judge  of  the  danger  of  an  action  by  the  pain  which  it 
produces,  because  some  slight  imperfections  and  irregularities  in  the  action  of  a 
part  will  produce  a  much  more  acute  sensation  than  some  very  dangerous  actions. 
It  is  an  old  observation,  that  pain  without  inflammation  may  be  borne  long  with- 
out very  great  injury  to  the  system. 


126 

Many  actions  are  thus  kept  up  longer  than  tbey  otherwise 
would  be,  and  may  then  be  interrupted  by  causes  which, 
formerly,  would  not  have  operated  to  poduce  this  effect. 
Other  actions  are  said  to  be  renewed,  or  restored  by  habit ; 
an  explanation  of  which  has  been  already  given. 

Twenty-sixth.  All  general  actions  exhibit  a  certain  revo- 
lution, or  exacerbation  and  remission,  at  particular  times  or 
periods.  In  a  state  of  health,  we  observe,  that  the  power  or 
energy  of  the  system  is  greatest,  and  the  action  most  perfect, 
in  the  morning.  In  the  evening,  the  action  is  more  imper- 
fect, and  the  power  less,  in  so  much,  that  in  very  weak  peo- 
ple, we  even  find  a  degree  of  fever  induced.  During  rest,* 
the  performance  of  the  functions,  or  the  different  parts  of  the 
natural  action,  is  lessened,  and  the  operations  of  the  mind, 
which  consume  much  energy  by  their  continuance,  are  lull- 
ed or  suspended.  There  is  then  a  regular  revolution,  which 
must  take  place  from  the  very  first  day  in  which  we  begin  to 
observe  regular  periods  of  sleeping  and  working  ;f  and  this, 
by  long  continuance,  and  frequent  repetition,  comes  to  be  so 
permanently  established,  that  even  although  we  remain  the 
whole  twenty-four  hours  without  exertion,  and  in  a  recumbent 
posture,  we  should  be  sensible  of  the  changes.  This  revolu- 
tion, which  takes  place  during  health,  continues  also,  by  ha- 
bit, during  disease,  al  hough  no  greater  exertion  be  made  dur- 
ing the  day  than  during  the  night ;  and,  hence,  we  may  ac- 
count for  the  greater  frequency  of  ihe  pulse,  and  the  exacer- 
bation of  many  diseases  toward  the  evening.     The  same  ob- 


*  Man,  in  a  state  of  nature,  would  uaturally  suspend  his  operations  when  the- 
*un  set,  even  although  he  was  not  led  to  do  so  from  fatigue.  He  worXs  through  the 
day  by  the  light  of  the  sun;  and  retires,  during  the  darkness  of  the  night,  to  rest 
from  his  labours. 

f  In  the  infant,  there  are  no  regular  periods  for  retiring  to  rest ;  but  the  child 
sleeps  repeatedly  during  the  twenty-four  hours,  at  no  stated  intervals.  The  young- 
er the  child,  the  more  sleep  is  required ;  that  is  to  say,  the  less  action  can  it  suc. 
tain. 


127 

servation  may  also  teach  us,  why  we  not  unfrequently  per- 
ceive remissions  toward  the  evening,  in  diseases  of  an  inflam- 
matory nature  ;  because  the  natural  action  is  naturally  less 
toward  night ;  and,  as  the  inflammatory  action,  in  healthy 
people,  consists  in  a  morbid  increase  of  the  action,  we 
may  understand  how  there  should  be  a  diminution  of  this 
at  night.  The  pulse,  in  acute  rheumatism,  is  often  quicker 
through  the  day  than  in  the  evening:  but  if  the  inflam- 
mation be  of  a  different  kind,  it  may  be  increased  by  the 
same  cause  which,  in  acute  rheumatism,  diminished  it.  In- 
flammation of  strong  parts,  in  healthy  people,  is  increased  by 
whatever  increases  the  natural  action,  and  vice  versa;  but  in- 
flammation of  weakened  parts,  or  in  reduced  and  weak  bodies, 
is  diminished  by  whatever  tends  to  improve  and  strengthen 
the  natural  action.  The  one  disease  will  be  worse,  the  other 
better  in  the  day  than  at  night. 

The  state  of  the  sun,  but  particularly  the  moon,  with  re- 
gard to  our  planet,  likewise  affects  the  human  body  ;  and  the 
way  in  which  it  does  so  has  been  already  mentioned.  When 
the  attractive  power  of  the  moon  operates  most,  the  actions 
of  the  system,  whether  healthy  or  diseased,  are  most  excited, 
that  is  to  say,  there  is  at  that  time  an  agent  acting  in  a  great- 
er degree  upon  the  body  than  at  another  time ;  and,  conse- 
quently, the  action  must,  at  that  time,  be  greatest.  When 
the  attractive  power  is  least,  diseased  actions  are  most  easily 
overcome,  if  all  the  other  causes  be  alike  ;  but,  if  other 
causes  interfere,  as  often  happens,  this  diminution  will  not  be 
perceived.  If  this  account  be  true,  we  shall  see  why,  at 
certain  periods  of  a  lunation,  diseases  ought  to  subside  most ; 
but  every  disease,  in  every  person,  will  not  subside  equally  ; 
for  those  which  have  recently  commenced,  will  not  be  so 
much  diminished  as  those  which  have  continued  longer,  and 
are  nearer  their  natural  termination.  If  near  the  end  of  a 
disease,  the  termination  may  be  hastened  br  the  diminution 


128 

• 
of  the  attraction  of  the  moon ;  if,  on  the  contrary,  the  dis- 
ease be  increasing,  it  will  be  aggravated  by  the  other  state  of 
the  moon,  in  which  it  acts  most,  and  may  thus  prove  fatal 
sooner  than  it  otherwise  would  do.^  This  being  the  case,  I 
do  not  see  that  the  doctrine  of  critical  days  can  be  explained 
by  this  general  principle,  which  must  either  be  allowed  to 
act  equally  on  all,  and  produce  a  crisis  in  every  disease  on  the 
same  day ;  or,  as  I  have  supposed,  must  operate  differently 
according  to  the  state  of  ihe  disease,  without  any  reference  to 
the  completion  of  a  regular  period,  or  certain  number  of 
days. 


Conclusion. 

From  the  whole  history  of  the  nervous  system,  its  pro- 
perties appear  to  be  wonderful  indeed,  and  its  delicacy  seems 
to  be  so  great,  that  we  would  at  first  suppose,  that  it  should 
be  perpetually  subject  to  derangement,  from  the  action  of 
even  the  most  trifling  cause.  But  by  a  more  attentive  ex- 
amination, we  perceive  here,  as  in  other  cases,  with  admira- 
tion, the  workmanship  of  an  infinitely  wise  and  powerful 
Creator,  who  has  established  such  laws  in  the  animal  econo- 
my, that,  in  many  cases,  these  huriful  powers  operate  for 
their  own  destruction.  When  a  foreign  body  is  applied  to 
the  nose,  it  is  expelled  by  sneezing  :  When  it  ge;s  into  ihe 
eye,  the  lachrymal  gland,  by  its  stimulus,  pours  out  more 
tears,  and  the  substance  is  washed  out  :  When  cantharides 
are  applied  to  the  skin,   the   cuticle  becomes  elevated,  and 


*  The  increased  attraction  of  the  moon  will  operate  most  visibly  on  the  diseases 
which  are  increasing,  whilst  the  effects  of  diminished  attraction,  will  be  most 
perceptible  when  the  disease  is  declining. 


129 

the  source  of  irritation  is  removed  far  from  the  true  skin ; 
or,  if  it  should  reach  to  it,  pus  is  soon  formed,  and  the  sti- 
mulus is  again  removed,  more  disagreeable  effects  being  thus 
prevented.  When  a  hurtful  matter  is  received  into  the  sto- 
mach and  bowels,  ils  first  operation  produces  vomiting  or 
purging,  and  thus  causes  its  own  expulsion,  as  is  some  limes 
seen  in  over  doses  of  arsenic,  or  dher  poisons.  When 
much  of  the  skin  is  inflamed,  the  action  of  the  internal  parts 
is  diminished,  the  action  of  the  heart  is  weakened,  and  the 
blood  is  sent  less  forcibly  to  the  surface.  The  inflammation, 
which  would  otherwise  soon  have  terminated  in  mortification 
thus  more  readily  admits  of  resolution.  When,  on  the  other 
hand,  the  action  of  the  cuticular  nerves  is  weakened,  the 
heart  has  its  action  increased,  the  blood  is  more  powerfully 
propelled,  and  the  nerves  of  the  surface  are  soon  again  sti- 
mulated to  their  proper  action.  Equal  nicety  is  displayed 
in  the  natural  actions  of  the  different  parts  of  the  animal. 
When,  for  instance,  the  light  is  faint,  the  iris  opens  to  admit 
the  most  to  the  retina  ;  but  when  it  is  vivid,  then  the  iris 
contracts,  and  allows  a  smaller  portion  of  rays  to  enter. 

These  properties  of  the  animal  evince  so  much  wisdom, 
that  many  have  been  led  to  imagine,  that  some  intelligent 
agent  presided  in  the  system,  and  regulated  all  its  actions. 
This  agent  has,  by  some,  been  believed  to  be  the  rational 
soul,  and,  by  others,  a  certain  preserving  power  of  nature  ; 
and,  accordingly,  the  vis  conservatrix  naturae  has,  at  all 
times,  held  an  eminent  situation  in  the  schools  of  physic. 
But  the  truth  is,  that  the  nervous  system  is  so  formed,  that 
these  happy  effects  take  place  regularly  from  the  immediate 
action  of  stimuli,  and  not  by  the  intermedium  or  direction  of 
any  third  power.  We  are,  accordingly,  not  led  up  to  any 
visionary  ai  cheus,  as  a  source  of  action ;  but  we  are  directed 
to  admire  the  wisdom  of  the  Almighty  Framer  of  man, 
who  established,  in  his  system,  the  laws  by  which  these  ope- 

VOL.    I.  R 


130 

rations  are  produced,  when  he  "  breathed  the  breath  of  life 
into  his  nostrils." 

Nor  is  this  all  which  we  have  to  admire  in  the  economy 
of  life ;  for  the  whole  history  of  it  is  full  of  wonder ;  from 
the  womb  even  to  the  grave.  The  conception  of  the  foetus  ; 
its  growing  from  the  uterus,  like  the  leaf  from  the  plant ;  con- 
nected to  its  parent  by  only  a  very  slender  vessel ;  its  in- 
creasing by  the  nourishment  of  the  mother ;  and  its  union 
with  an  immaterial  and  immortal  spirit ;  are  all  mysterious, 
and  truly  wondeiful  points;  but  not  more  so,  than  its  re- 
ceiving, after  birth,  foreign  matters  into  the  stomach ;  its 
changing  their  life  into  its  own,  and  converting  them  finally 
into  a  part  of  itself;  its  gradual  increase  from  an  imper- 
ceptible point  to  a  full  grown  creature ;  and  its  equally  slow 
and  regular  progress  from  maturity  to  dissolution  ;  are  topics 
which  are,  indeed,  worthy  to  be  seriously  contemplated  by 
the  most  exalted  mind. 

"  Fearfully  and  wonderfully  are  we  made." 


DISSERTATION  II. 


•N    SIMPLE    INFLAMMATION,    AND    ITS    CONSEQUENCES- 


Of  the  Definition  and  Division  of  Inflammation. 

BY  (he  term  inflammation,  is  generally  understood  that 
state  of  a  part,  in  which  it  is  painful,  hotter,  redder,  and 
somewhat  more  turgid,  lhan  it  naturally  is;  which  topical 
symptoms,  when  present  to  any  considerable  degree,  or  when 
they  affect  very  sensible  parts,  are  attended  with  fever,  or  a 
general  diseased  action  of  the  system. 

The  most  obvious  division  of  the  action  of  inflammation,  is 
into  ihat  affecting  strong  and  healihy  parts,  and  that  affecting 
those  which  are  weak ;  and,  therefore,  the  order  inflammatse 
will  consist  of  two  genera,  the  inflammatio  valida,  and  the  in- 
fiammaiio  debilis :  the  specific  distinctions  will  be  the  same  in 
boih  of  these  genera,  being  founded  upon  the  part  affected : 
the  varieties  depend  upon  the  duration  and  activity  of  the 
action  :  that  which  runs  its  course  rapidly  and  actively,  is 
called  inflammatio  activa,  sive  acuta ;  that  which  continues 
longer,  and  seems  to  have  become,  in  a  manner,  habitual  to 
the  part,  is  termed  inflammatio  passiva,  sive  assuefacta. 
Some  of  the  species  wijl  naturally  admit  of  only  the  first 
variety. 


L3'2 

It  is  the  inflamniatio  valida  et  acuta  which  is  here  to  be 
considered  at  greatest  length :  the  inflammatio  debilis  will 
come  to  be  attended  to,  in  examining  the  causes  and  treat- 
ment of  mortification  :  the  little  which  is  necessary  to  be  said 
concerning  the  inflammatio  assuefacta,  will  be  mentioned  in 
the  conclusion  of  this  dissertation. 

Of  the  Stages  and  Terminations  of  Inflammation. 

In  every  extensive  inflammation,  we  may  always  observe 
two  stages,  which  are  marked  by  different  symptoms,  those 
of  i  he  one  being  common  to  every  new  action,  during  its  for- 
mation, whilst  those  of  the  other  are  peculiar  to  the  disease  at 
present  to  be  considered. 

In  the  first  stage,  the  patient  is  weak  and  languid,  and  com- 
plains of  coldness ;  the  pulse  is  frequent  and  small ;  the 
tongue  parched  ;  the  head  somewhat  confused  or  pained,  and 
the  functions  of  the  stomach  deranged. 

In  the  second  stage,  the  pulse  becomes  harder ;  the  thirst 
continues  ;  the  coldness  is  succeeded  by  heat,  and  the  patient 
bei  omes  restless  and  uneasy.  Whenever  these  symptoms 
appear,  the  local  disease  manifests  itself,  and  keeps  pace  with 
the  general  affection :  the  part  becomes  red,  painful,  and 
swelled,*  at  the  same  time  that  its  function  is  impaired. 

When  this  topical  affection  supervenes,  the  fever  seldom, 
except  in  some  specific  diseases,  abates ;  but,  on  the  contrary, 
often  becomes  nioie  violent,  and  continues  until  the  local  dis- 
ease be  either  removed,  or  its  nature  be  changed. 

W  hen  inflammation  is  suddenly  produced  by  any  powerful 
cause  acting  locally,  we  find,  that  the  local  affection  comes  on 
first,  after  which  the  febrile  symptoms  appear.     If,  however, 


*  The  softest  parts  swell  most ;  those  which  are  harder  swell  less,  with  the  saint 
degree  of  inflammation, 


133 

the  local  complaint  be  slight,  and  induced  by  a  trifling  cause, 
we  do  not  find,  that  any  general  disease  is  induced,  but  the 
affection  is  entirely  topical. 

When  the  fever  does  not  come  on  until  after  the  establish- 
ment of  the  inflammatory  action  in  a  part,  ii  is  called  sympto- 
matic, being  dependent  entirely  on  the  local  affection  :  but 
when  the  fever  precedes  the  topical  inflammation,  or  is  co- 
eval with  it,  then  it  is  said  to  be  idiopathic,  being  produced 
by  the  direct  operation  of  the  same  causes  which  induce  the 
topical  disease.  In  all  cases,  perhaps,  the  fever  becomes 
symptomatic  in  the  end. 

When  the  local  inflammation  can  be  removed,  without  any 
very  remarkable  change  being  induced  in  the  part,  it  is  said 
to  be  resolved,  or  to  terminate  by  resolution  ;  a  term  wh  h 
originated  from  the  ancient  doctrines  on  this  subject.  This 
is  known  to  have  happened,  by  the  diminution  at  first,  and  af- 
terwards the  complete  removal  of  the  different  symptoms, 
whilst  the  part  slowly  returns,  apparently,  to  its  natural  figure, 
although,  most*  frequently,  there  are  adhesions  formed  with 
the  contiguous  parts. 

When  the  pain,  heat,  and  redness,  disappear,  but  the  part 
remains  hard  and  swelled,  the  inflammation  is  said  to  end  in 
schirrus.  This  termination  is  most  frequent  in  glandular 
parts. 

If,  on  the  contrary,  the  pain,  redness,  and  heat,  continue 
great  for  some  time,  and  then  abate,  the  first  becoming  still 
more  of  the  pulsatory  kind,  at  the  same  time  that  the  part  re- 
mains swelled,  but  becomes  gradually  soft  and  fluctuating;,  and 
especially  if  this  change  be  preceded  by  dullness,  we  may 
be  certain,  that  the  structure  of  the  part  is  destroyed,  and  a 

*  Adhesions  are  formed  in  every  instance  where  the  inflammation  is  produced  by 
mechanical  injuries;  but  where  it  depends  upon  some  general  cause,  adhesions  do 
not  always  take  place.  This  is  exemplified  by  rheumatism,  where  adhesions  are  not 
necessarily  produced. 


134 

new  secretory  action  established,  producing  pus,  which  fills 
the  cavity  formed  by  the  destruction  of  the  inflamed  parts. 
In  this  case,  the  inflammation  is  said  to  terminate  by  suppu- 
ration :  at  other  times,  especially  in  inflammation  of  mem- 
braneous parts,  which,  in  health,  secrete  a  particular  fluid,  a 
liquid,  different  from  pus,  and  resembling  more  the  natural  se- 
cretion of  the  part,  is  formed.  In  this,  as  in  the  other  case, 
the  inflammation  diminishes ;  but  the  patient  has  seldom  any 
chills;  nor  is  the  structure  of  the  part  injured,  at  least  farther 
than  by  mere  distension,  if  it  be  a  cavity.  The  functions  of 
the  part  are,  however,  often  injured,  from  the  presence  of 
the  fluid.  This  termination,  which  has  been  improperly 
called  effusion,  is  not  uufrequent  in  pulmonic  affections,  pro- 
ducing hydrothorax  :  It  likewise  produces  the  thick  discharge 
from  the  nose,  in  catarrh,  and  the  purulent  looking  discharge 
which  takes  place  from  the  urethra,  after  the  application  of 
acrid  matters. 

Lastly.  Violent  inflammation  in  a  part  may  kill  it,  in  which 
case  it  is  said  to  end  in  mortification.  We  are  to  apprehend 
this  termination,  when  the  inflammation  is  very  violent,  com- 
pared to  the  power  of  the  part,  and  when  it  manifests  no  ten- 
dency to  any  of  the  other  terminations.  We  are  still  more 
to  dread  it,  when  the  colour  of  the  part  becomes  of  a  darker 
hue,  and  the  pulse  more  frequent  and  feebler,  at  the  same 
time  that  the  general  strength  sinks.  In  these  circumstan- 
ces, if  the  disease  be  not  checked  by  proper  remedies,  the 
"mortification  soon  appears  :  the  part  becomes  first  of  a  purple, 
and  then  of  a  black  colour:  it  loses  its  heat;  the  cuticle  rises 
up  in  blisters,  and  the  part  soon  becomes  soft,  putrid,  and 
quite  senseless.  This  termination  does  not  take  place  with- 
out much  pain ;  for  although  the  part,  after  it  mortifies,  has 
no  feeling,  yet,  during  the  process,  the  sensation  is  very 
acute  ;  and,  even  after  the  mortification  is  complete,  the  parts 
in  the  immediate    vicinity  are  excessively  irritable,    being 


135 

nearly  in  the  same  state  in  which  the  mortified  part  was  before 
it  died. 

When  the  mortification  effected  only  the  cellular  substance, 
it  was  supposed  to  be  of  a  milder  nature,  and  was  called  gan- 
grene; bu!  when  it  penetrated  deeper  to  the  muscles  or 
blood-vessels,  it  was  called  a  sphacelus. 

Of  the  Exciting  Causes  of  Inflammation. 

Whatever  increases  the  action  of  a  part,  beyond  that  rela- 
tion which  ought  to  subsist  betwixt  the  action  of  a  part  and  its 
power,  is  productive  of  inflammation.  The  causes  which 
effect  this  may  be  divided  into  two  classes  ;  first,  those  which 
act  directly  on  the  part  to  which  they  are  applied ;  second, 
those  which  are  not  applied  to  the  part  which  becomes  in- 
flamed, but  which  act  indirectly  on  it. 

The  first  kind  admits  of  \wo  divisions.  First,  those  foreign 
agents  which  operate  by  what  is  called  their  stimulant  power, 
su  h  as  cantharides,  heat,  &c.  This  operation  having  been  al- 
ready explained  in  the  preliminary  dissertation,  it  will  be  un 
necessary  to  make  any  further  remark  on  it  liere.  Second,  those 
causes  whi  h  act  mechanically,  such  as  bruises  and  wounds. 
B'uises  act,  I  apprehend,  in  the  same  way  with  cold,  when  il 
appears  to  inflame  the  part  to  which  it  is  applied  ;  and,  there- 
fore, their  action  will  be  explained  in  considering  the  opera- 
tion of  cold.  If  wounds  be  put  into  a  proper  situation  of 
uniting,  we  generally  find,  that  no  inflammation  takes  place ; 
but  ihe  stru  sure  of  the  part  is  directly  renewed,  by  the 
operation  of  the  same  power  which  nourishes  the  part  in 
health,  and  renews  its  structure  when  absorbed  :  But  if  Horn 
any  cause  this  be  prevented,  then  inflammation  comes  on, 
from  which  we  may  presume,  that  the  prevention  of  the  ac- 
tion of  nutrition  produces  the  inflammatory  action  ;  for  if, 
by  removing  the  sides  of  the  wound  from  each  other,  or  by 


136 

any  other  cause,  we  inevitably  prevent  the  natural  action  of 
deposition,  or  nutrition,  then  the  most  trifling  cause  will  in- 
duce the  inflammatory  action ;  even  the  circumstance  of 
being  in  an  unusual  situation,  will  be  sufficient  to  excite  the 
action  to  a  morbid  degree.*  On  the  other  hand,  the  pre- 
sence of  the  inflammatory  action,  will  be  sufficient  to  pre- 
vent the  action  of  nutrition,  if  it  should  be  excited  by  the 
operation  of  the  cause  which  produced  the  injury  ;  for  the 
wound  is  often  inflicted  in  such  a  way,  or  with  such  pain,  as 
to  increase  the  action  to  such  a  degree  as  to  form  inflamma- 
tion ;  and  this  cause  will  more  especially  operate,  where  we 
interrupt  the  uniting  process,  or  action  of  nutrition  :  It  is  even 
often  sufficient  to  cause  inflammation,  when  we  use  every 
precaution  to  forward  the  uniting  process.  Cold  is  very 
often  found  to  inflame  the  part  to  which  it  is  applied  ;  but  it 
has  not  been  deemed  easy  to  give  such  an  explanation  of  its 
action  as  would  be  applicable  to  every  case.  It  was,  at  one 
time,  supposed  to  operate,  by  producing  stagnation  of  the 
blood,  or  humours  in  the  part ;  but  the  two  opinions  which  I 
shall  at  present  mention,  are,  1st.  That  it  acts  as  a  stimulant; 
2d.  That  it  acts  as  a  sedative. 

In  support  of  the  opinion,  that  cold  is  a  stimulant,  it  may 
be  urged,  that  it  produces  pain,  when  applied  in  too  great 
quantity  ;  that  it  reddens  the  skin,  and  often  inflames  the 
part  on  which  it  acts  ;  and,  finally,  that  it  invigorates  the 
system,  when  applied  in  moderation. 

It  must,  however,  be  evident  to  every  one,  that  cold 
lessens  the  action,  either  of  the  whole  system,  or  of  a  part, 
according  to  the  mode  of  its  application  ;  and  that,  if  it  be 
long  enough  continued,  it  will  produce,  first,  torpor,  and  then 
death.     This  is  so  fully  established,  that  it  is  unnecessary 

*  Mr.  Hunter  supposes,  that  the  "  stimulus  of  imperfection  immediately  calli 
forth  the  action  of  restoration,"  which  is  effected  by  means  of  inflammation. 

Hunter  on  Inflammation,  p.  190 


137 

to  insist  upon  it ;  and  must  prove,  that  cold  is  not  a  stimulant. 
Pain  is  produced,  both  by  an  increase  and  diminution  of  ac- 
tion; and,  therefore,  we  are  not  to  be  surprised,  that  cold 
should  be  productive  of  a  very  unpleasant  sensation  or  pain. 
The  absence  or  diminution  of  any  accustomed  stimulus,  must 
be  productive  of  pain  ;  and  this  pain  will  be  violent,  in  pro- 
portion to  the  extent  and  continuance  of  the  diminution. 
The  want  of  food  produces,  1st.  Slight  uneasiness,  and  then 
more  acute  pain  ;  and  the  same  may  be  said  of  heat. 
Whenever  any  natural  and  accusJomed  stimulus  is  withdrawn, 
the  action  of  the  part  is  performed  irregularly,  and  becomes 
imperfect,  which  is  always  attended  with  a  disagreeable  sen- 
sation :  But,  besides  this  cause  of  pain,  there  is  also  another, 
which  comes  to  operate  after  the  cold  has  been  applied  for  a 
considerable  time,  namely,  that  the  action  of  the  neighbour- 
ing parts  is  communicated  by  sympathy  to  the  cold  part, 
which  occasions  an  action  in  it  greater  than  the  power  can 
sustain,  and,  consequently,  produces  a  species  of  inflamma- 
tion.^ There  are,  likewise,  several  causes  which  may  be 
applied  at  the  same  time  with  the  cold,  and  which  will  tend 
to  excite  action,  and,  consequently,  produce  pain  in  the 
weakened  part.  Thus,  the  percussion  of  the  air  stimulates 
and  causes  pain ;  hence,  rain  or  snow,  drifted  in  the  face, 
produces  much  more  pain  than  when  it  flies  more  gently,  al- 
though, in  both  cases,  the  temperature  be  the  same. 

That  cold  produces  redness,  is  no  proof  that  it  is  a  stimu- 
lant ;  for  this  redness  is,  at  first,  produced  by  a  diminished 
circulation,  the  blood  remaining  longer  in  the  veins  ;  and, 
therefore,  the  part  becomes  of  a  purple  hue,  which  is  very 
different  from  the  bright  red,  produced  by  the  direct  action 
of  a  powerful  stimulant. 

•  See  Prelim.  Divert,  p.  133, 
VOL.    I.  S 


138 

It  may  also  be  said,  that  cold  stops  bleeding,  and  lhat  alco- 
hol does  the  same,  therefore  cold  is  a  stimulant ;  but  it  is  to 
be  remembered,  that  there  exists  this  material  difference,  that 
cold  s'ops  active,  and  alcohol  passive  haemorrhage.  Cold  has 
likewise  been  supposed  to  be  a  stimulant,  from  ihe  invito  at- 
ing  effects  of  the  cold  bath ;  but,  in  order  that  cold  may  in- 
vigorate, it  is  necessary  that  it  be  applied  for  only  a  short 
time,  and  be  frequently  repealed ;  it  thus,  by  diminishing  the 
'%  action  of  the  surface,  increases  that  of  the  internal  parts,  and 

thus  strengthens.  That  cold  does  not  inflame,  by  its  stimu- 
lant power,  will  be  immediately  seen. 

Those  who  main  Iain  cold  to  be  a  sedative,  have  been  under 
the  necessity  of  maintaining)  that  it  never  inflamed  unless 
some  direct  stimulant  was  afterwards  applied;  or  that,  by  re- 
laxing the  vessels,  it  made  them  admit  more  blood,  and  thus 
produt  ed  a  kind  of  inflammation  ;  but  it  is  to  be  remember- 
ed, thai  in  the  living  syslem,  blood  does  neither  accumulate 
in  a  pari,  nor  is  its  quantity  diminished  by  any  general  mecha- 
nical cause  operating  on  o. her  parts,  or  by  any  affection  of  the 
propelling  cause,  but  that  ihe  state  of  the  vessels,  with  re- 
gard to  blood,  depends  upon  their  own  condition.  Weak- 
ness, in  any  part  of  the  arterial  system,  ought  to  diminish 
the  quantity  of  blood  in  that  part :  Weakness,  in  the  veinous 
system,  will  indeed  produce  accumulation  of  blood  ;  but  this 
cannot  produce  inflammation.  Cold,  then,  cannot  act  by  its 
relaxing  power.  Experience  likewise  proves,  that  cold  may 
induce  inflammation,  wishout  requiring,  for  this  purpose,  the 
subsequent  application  of  heat,  or  any  other  artificial  stimulus. 

Cold  may  operate  on  a  part,  and  destroy  it  in  three  dif- 
ferent ways.  Fiist,  it  may  be  applied  in  such  a  degree,  and 
for  su.h  a  length  of  time,  as  to  destroy  the  vitality  of  the 
part  directly ;  in  which  case,  sloughs  are  formed.  Second., 
it  may  be  applied  in  a  less  degree,  or  for  a  shorter  time ;  and 
afterwards  a  stimulant,  such  as  heat,  may  be  applied,  which 


139 

will  excite  inflammation.  The  production  of  inflammation, 
by  any  agent,  depends,  in  a  great  degree,  upon  the  sudden- 
ness of  the  operation  of  the  agent  which  exci.es  it;  for  a 
quantity  of  stimulus,  which,  if  suddenly  applied,  will  produce 
inflammation,  may  be  applied  slowly  with  impunity.  F.om 
which  ii  will  follow,  thai  any  given  stimulant  mus,  more  easi- 
ly produce  inflammation,  in  a  part  which  has  a  low  action, 
than  in  one  having  a  vigorous  action,  ihere  being  a  greater 
disproportion  in  the  one  case  than  in  the  other,  betwixt  the 
action  induced  by  the  agent  and  ihe  previous  action  of  the 
part.  Hence,  very  slight  stimuli  will  induce  inflammation; 
in  parts  which  have  been  weakened  by  cold.  Thid,  it  has 
been  already  mentioned,  that  a  part  sympathises  ve<y  much 
with  those  which  are  contiguous  to  it.  If  a  part  be  weaken- 
ed, by  having  its  action  reduced,  and  if  then  the  debilitating 
cause  be  removed,  the  action  of  the  part  will  be  increased, 
or  excited,  by  its  sympathy  wi^  he  neighbouring  aeting 
parts:  But,  as  the  action  ought  to  be  very  liiie,  ihe  power 
being  small,  it  will  follow,  thai  disease,  or  inflammation,  must 
arise  from  this  cause,  the  ac  ion  being  increased  beyond  the 
power.  We  ought,  therefo;e,  in  this  case,  to  diminish  the 
action  of  the  neighbouring  parts,  in  order  to  prevent  their 
extending  their  action  to  a  part  which  is  not  able  to  bear  it 
without  becoming  diseased. 

These  remarks  may  suffice,  with  regard  to  the  causes  of 
inflammation  which  belong  to  the  fust  class.  I  come  now  to 
consider  those  of  the  second  kind,  or  those  which  operate, 
not  upon  the  part  to  which  they  are  applied,  but  upon  distant 
parts,  the  chief  of  which  causes  is  cold. 

Cold,  applied  to  the  surface  of  the  body,  often  inflames 
the  internal  parts.  This  has  been  often  observed,  and  vari- 
ous explanations  of  it  have  been  attempted  ;  whilst  others 
have  denied  the  existence  of  the  fact. 


140 

Dr.  Brown  supposed,  that  cold,  at  no  time,  produced  in- 
flammation of  internal  parts,  unless  it  were  applied  to  those 
parts,  and  had  heat  applied  after  it ;  or,  in  other  words,  that 
cold  acted  always  in  one  way,  and  never  on  any  part  to  which 
it  was  not  directly  applied.  He,  therefore,  classed  the  lungs 
amongst  the  external  parts,  in  order  to  account  for  peripneu- 
mony  being  produced  by  cold.  He  did  not  remember, 
however,  that  the  pain  and  cough  sometimes  make  their  ap- 
pearance, whilst  the  patient  is  still  exposed  to  the  cold,  and 
before  heat  has  been  allowed  to  operate.  He  likewise  for- 
got, that  the  temperature  of  the  lungs  is  not  affected  by  the 
temperature  of  the  surrounding  air,  being  neither  warmed  by 
warm  air,  nor  cooled  by  cold  air.  The  lungs  are  to  be  con- 
sidered as  the  centre  of  the  circulation,  with  regard  to  animal 
heat,  the  heart  being  only  a  muscle  subservient  to  them. 
But,  granting  that  the  lungs  could  be  warmed  or  cooled,  it  is 
to  be  remembered,  that  a  person  riding  in  a  cold  night,  will 
often  have  a  sore  throat,  or  pain  in  his  breast  produced,  (if 
the  integuments  covering  these  parts  have  been  exposed,) 
before  he  alight,  and,  consequently,  before  he  could  be  ex- 
posed o  heat.  If  this  take  place  in  one  instance,  the  theory 
must  be  false. 

Dr.  Cullen  supposes,  that  cold  inflames  distant  parts,  by 
affecting  >he  course  of  (he  fluids.  When  applied  to  the  sur- 
fa  e,  it  inflames  the  lungs,  in  his  opinion,  by  obstructing  the 
perspiration,  and  vhus  determining  lo  the  lungs.  Cold  is 
likewise  applied,  he  supposes,  to  the  lungs  themselves,  at 
the  same  time.*  Now,  wc;c  this  the  case,  the  lungs  ought 
not  to  be  affected  :  for  if  cold  were  capable  of  acting  on  the 
lungs,  ii  should  obstruct  the  exhalation  from  them,  as  well 
as  the  perspiration  from  the  skin  ;  therefore,  some  intermedi- 
ate point,  and  not  the  lungs,  would  be  injured. 

*  Cullen's  First  Lines,  &c.  Vol.  I.  par.  345. 


141 

The  same  idea,  although  with  some  modification,  is  adoptr 
edby  Mr*  Abeme.hy,*  who  supposes,  that  air  is  thrown  out 
from  !he  blood,  along  with  the  matter  of  perspiration  ;  and, 
tl:  be,  ;hat  when  the  perspiration  is  diminished,  the  de- 
q  of  Quids  to  the  lungs  is  particularly  to  be  expect- 
ed ;  because,  as  ihe  air  whi  h  went  off  with  the  perspiration 
is  now  retained,  i;  goes  to  the  only  oiher  place  where  it  can 
ge;  otii,  namely,  the  lungs,  "where the  secretion  is  similar  to 
the  one  vjbtch  has  been  suppressed;"  by  which  suppression 
the  blood  has  "  become  su  barged  with  air,  to  which  the 
Jungs  o.ily  *an  affo  d  an  ou:iei." — "  Thus,  an  accumulation  of 
fluids,  in  the  pulmonary  vessels,  will  ensue." 

These  explanations  of  the  action  of  cold,  evidently  over- 
look the  aciion  of  the  nerves,  and  the  true  his  lory  of  diseases  ; 
for  no  "increased  determina; ion  of  fluids"  can  take  place 
without  increased  nervous  action.  The  sympathies  of  fluids 
and  vessels,  wee  once  indeed,  favourite  doctrines  in  the 
schools  ;  and  ihe  trifling  and  un  -eriain  anastomosis  of  arte- 
ries or  veins  were  anxiously  looked  for.  But  the  fluids  must 
now  be  considered  as  subordinate  agents,  and  the  changes 
and  diseases  of  the  living  system  traced  to  a  higher  source 
than  hydraulic  principles. 

Seeing,  then,  that  none  of  these  opinions  give  a  satisfacto- 
ry explanation  of  th  manner  in  which  cold,  when  applied  to 
the  surface,  inflames  the  internal  parts,  we  must  have  re- 
course to  another  principle,  or  to  the  sympathy  of  equilibrium, 
by  which,  I  apprehend,  the  fact  may  be  sufficiently  ex- 
plained. 

Cold,  applied  in  a  moderate  degree,  to  the  whole  surface, 
diminishes,  for  a  time,  the  action  of  the  skin,  but  raises  that 
of  the  internal  parts,  and  thus  produces  strength,  if  the  ap- 
plication be  frequently  repeated  ;  these  parts  being  the  most 


*  Abcrnothy's  E^ays,  p.  150. 


142 

essential  to  the  animal,  and  those  on  which  its   health  and 
vigour  <  hiefiy  depend. 

This  effect  of  <  old,  in  raising  or  exciting  the  action  of  the 
internal  parts,  when  applied  Jo  the  surface,  is  also  seen  in  the 
benefi  which  is  derived  from  dashing  cold  water  on  the  thighs 
and  legs,  in  cases  of  cosliveness  or  suppression  of  mine,  de- 
pending on  torpor  of  the  intestines  or  bladder.  Upon  the 
same  principle,  we  may  account  for  the  occasional  bad  effects 
of  the  cold  baih,  when  applied  partially ;  fo  ,  in  his  ase,  !he 
parts  which  are  out  of  he  water,  may  have  iheii  action  mor- 
bidly increased,  by  the  diminution  of  ac  ion  in  those  pa-ts 
which  were  immersed.  Hence,  ihe  popular  opinion,  ha'  if 
bathers  do  not  plunge  the  head  under  he  water,  hey  will 
have  head-a  he  produced,  is  not  !otally  withou:  foundation. 

If  the  cold  be  applied  !o  the  surface  for  a  considerable  ime, 
or  to  such  a  degree  as  to  reduce  ihe  temperature  of  ihe  skin 
considerably  below  that  which  obtained  befo-e  the  appli  a- 
tion,  inflammation  is  very  frequently  produced,  in  some  inter- 
nal part,  owing  to  the  morbid  increase  of  aciion  which  is  thus 
produced  in  it.  What  part  shall  suffer  thus,  will,  in  a  great 
measure,  depend  on  the  portion  of  the  surface  which  is  ex- 
posed, each  part  of  the  skin  sympathising  chiefly  with  ihe 
organs  immediately  under  it.  Cold  and  damp,  applied  to  'he 
feet,  are  very  apt  to  produce  inflammation  of  the  throat. 

Cold  will   most    readily  produce    inflammation,  when  the 

surface  has  had  its  action  previously  much  increased  by  heat. 

When  the  skin  of  the  throat  or  breast  is  very  warm,  and  is 

suddenly  exposed  to  cold,  cynanche  or  pneumonia  is,  in  nine 

v  cases  out  often,  pioduced. 

From  these  remarks  we  may  understand,  firstj  how  cold 
applied  to  the  surface,  in  a  certain  degree,  and  for  a  certain 
time,  inflames  the  internal  parts  ;  second,  how,  when  it  is  ap- 
plied to  a  greater  degree,  and  continued  for  a  longer  time,  it 
inflames  the  part  itself  on  which  it  directly  acts. 


113 

It  is  observable,  that  some  people  are  more  subject  to  in- 
flammation than  ohers;  and,  by  examination  we  shall  find, 
thai,  these  are  the  most  vigorous  and  plethoric.  This  con- 
dition, from  i!s  propensity  to  inflammation,  has  been  named 
the  phlogistic  diathesis.  This  slate  is  induced  by  the  use  of 
stimulating  and  highly  nourishing  diet,  invigorating  exercise, 
and  Uie  application  of  cold  in  such  a  way  as  to  prove  tonic. 

Inflamma.ion  is  readily  induced  in  such  people,  and  is  worse 
borne  by  :hem,  because,  as  Mr.  Hunter  has  observed,  their 
action  is  already  as  high  as  it  can  possibly  be,  without  caus- 
ing disease.  A  very  trifling  increase,  then,  which  will  be 
easily  indued,  must  be  productive  of  inflammation.  Hence, 
operations  are  borne  worse  by  healthy  people  than  by  those 
who  have  been  ailing  for  some  time.  Thee  is,  however, 
ano.her  <:ause  which  co-operates  with  this,  and  renders  ope- 
ra >;ons  safer  in  those  who  have  had  local  diseases  of  long  con- 
tinuance, than  in  those  who  have  met  with  sudden  accidents, 
namely,  that  the  constitution  has  been  long  accustomed  to 
diseased  or  lnflamma  o.y  aaion,  and  therefore,  is  better  able 
to  endure  ihe  action  which  is  induced  by  the  operation  ;  for 
mo  bid  actions,  which  are  suddenly  excited  in  a  healthy  sys- 
tem, aie  more  dangerous  than  those  which  come  on  more 
slowly.  Even  if  the  previous  action  had  not  been  inflamma- 
toiy,  ii  was  of  a  morbid  naiuie,  and  therefore,  should  make 
the  a-.tion  induced  by  the  operation  less  dangerous;  be-ause 
we  have  still  only  exchanged  one  diseased  action  for  another, 
and  not  excited  it  in  a  s}  stem  formerly  healthy. 

Of  the  Proximate  Cause  of  Inflammation* 

Concerning  the  proximate  cause  of  inflammation,  a  very 
great  diversity  of  opinion  has  p  evailed  ;  but  still  almost 
eve  y  theory  has  agreed  in  admitting  the  agency  of  an  ob- 
structing cause. 


144 

For  several  centuries,  the  opinions  which  were  held  on  this 
subject  were  very  much  the  same,  and  received  no  maerial 
change  until  «he  dis-ovcy  of  ihe  immortal  Ha  vey. 

Whilst  the  circulation    of  ihe    blood  was   unknown,  and 
whilst  the  hypothetical  notions  of  ihe  powe    of  ,he  live  ,  in 
preparing  and  sending  forth  this  fluid,  continued  o  p  erail,  it 
is  not  astonishing  that  the  theories  of  physic  should  be  ex- 
ceedingly imperfect.     So  fully  persuaded  we  e  physicians  of 
the  existence  and   agency  of  different  humours  and   spirits, 
and  so  litile  did  hey  know  of  he  regular  and  constant  motion 
of  the  blood,  that  they  believed  in  the  possibility  of  deposi- 
tions and  congestions  of  the  blood,  ihe  bile,  or  the   lymph ; 
and  acknowledged  these  as  the  cause  of  inflammation.     Their 
anatomists  taught  them,  and  their  professors  of  physic  sup- 
ported the  opinion,  that  the  liver  was  the  centre  of  the  vascu- 
lar system,  from  which  the  blood  went  forth  by  day  to  the 
extremities,  and  returned  again  by  night.     If,  then,  any  pec- 
cant matter  irritated  the  liver,  then  the  blood  was   sent  out 
more  forcibly  ;  and  if,  at  the  same  time,  any  part  of  the  body 
were  weakened,  or  otherwise  disposed  to  receive  a  greater 
quantity  of  fluid  than  the  rest,  then  a  swelling  was  produced 
by  the  flow  of  the  humours  to  this  place.    Fluxions,  or  flows 
of  humour  to  a  place,  might  happen  either  by  weakness  of  the 
part,  which  allowed  ihe  humours  to  enter  more  abundantly,  or 
by  the   place  attracting  the  humours,  in  cousequence  of  the 
application  of  heat,  or  other  agents.     When  the  fluxion  was 
produced  by  some  irritating  cause  applied  to  the  source  of  the 
blood  or  humours,  and  a  weakness  of  the  part  affected,  then 
the  part  was  said  to  be  passive ;  but  when  the  fluxion  arose 
from  some  cause,  acting  directly  on  the  part,  and  making  it 
attract  the  humours,  then  it  was  said  to  be  active.     Tht- 
teachers  of  medicine,  then,  had  two  great  heads  for    com- 
menting on  ;  first,  the  stale  of  the  part  transmitting  ;  and  se 
cond,  the  condition  of  the  part  receiving.    The  peculiar  na- 


14£ 

hire  of  these  tumors  depended  upon  the  humour  which  was 
sent  in  the  greatest  abundance  ;  blood,  for  instance,  produ- 
ced the  true  phlegmon ;  bile  produced  erysipelas,  &c. 

It  was  likewise  believed,  that  at  other  times,  the  part  might 
somehow  allow  the  blood  or  humours  to  stagnate  slowly  in  it, 
from  a  want  of  expulsive  power ;  or  might  detain  the  fluid, 
"  quae  in  loco  affecto  gignitur."  The  tumor  thus  produced, 
was  called  a  congestion,  to  distinguish  it  from  the  one  which 
arose  from  the  sudden  flow  of  humours  from  a  distant  part, 
and  which  was  called  a  fluxion  or  cleflvxion.  The  first  was 
formed  gradually,  without  much  pain,  or  the  feeling  of  pulsa- 
tion, and  run  its  course  slowly  ;  the  second  appeared  sudden- 
ly, was  very  painful,  had  a  pulsatory  feeling,  and  run  its  course 
rapidly. , 

As  the  blood  was  supposed  to  possess  very  little  motion, 
and  to  have  its  course  easily  diverted  or  changed,  by  very 
trifling  causes,  it  became  an  established  rule,  that  in  fluxions, 
we  should  endeavour  to  alter  the  direction,  or  "dete;mina- 
tion,"  of  this  fluid.  In  recent  inflammation,  they  laid  it  down 
as  a  fixed  principle,  to  bleed  from  some  part  which  was  dis- 
tant from  the  seat  of  the  disease,  by  which  they  imagined, 
that  the  current  was  changed,  and  a. revulsion  made.  If  the 
inflammation  was  above  the  liver,  which  they  said,  was  the 
centre  of  the  body,  considered  medically,  they  took  blood 
from  some  part  below  it;  when  one  side  was  affected,  Ihen 
they  bled  from  the  other.  They  likewise  made  a  catalogue 
of  the  different  veins  which  purged  the  different  parts,  or  de- 
tracted from  them  ;  and  this  assisted  them  in  their  practice. 
The  cephalic  vein  evacuated  the  head  ;  the  basilic,  the  parts 
farther  down;  whilst  the  median  detracted  from  both  parts: 
the  left  arm  evacuated  the  spleen,  and  the  right  one  the 
liver.  * 

*  The  natives  of  Thibet  and  Boutan  still  retain  similar  sentiments:  they  bleed 
in  the  neck,  when  they  wish  to  cure  pains  in  the  head  ;  the  cephalic  vein  is  orxn 
VOL.  I.  T 


146 

A  revulsion  was  also  effected,  by  raising  a  tumor  in  some 
other  part,  by  means  of  ligatures,  cupping  glasses,  &c;  or, 
by  giving  nature  an  opportunity  of  discharging  the  humours 
from  distant  parts,  by  applying  leeches  or  blisters  to  these  : 
hence,  sinapisms  were  applied  to  the  feet,  in  diseases  of  the 
superior  parts. 

If  it  were  not  convenient,  or  if  it  were  not  judged  proper, 
to  make  a  complete  revulsion,  then  blood  was  drawn  from  the 
neighbourhood  of  the  parts,*  and  this  was  called  derivation, 
which  differed  from  revulsion  only  "  in  the  measure  of  the 
distance  to  whi?h  ihe  humour  was  drawn."  As  this,  how- 
ever, was  supposed  raiher  to  draw  more  fluid  to  the  part, 
than  to  draw  from  it,  most  people  considered  it  as  dangerous 
to  use  derivation  in  the  beginning  of  the  disease. 

At  the  same  time  that  bleeding  was  used  copiously,  they 
also  applied  repellents  to  the  pari,  in  order  to  co-operate  with 
the  other  remedies.  These  consisted  of  astringents,  mixed 
with  an  innumerable  quantity  of  inert  diugs.  If,  on  the  con- 
trary, il  was  thought  improper  to  repel  the  matter,  then  the 
tumor  Mas  to  be  resolved  by  "  discussion,"  or  a  "  breathing 
out  of  the  humour,  by  insensible  transpiration  ;"  and  this  was 
effected  by  applications,  which  were  said  to  be  "  hot,  subtle, 
and  powerfully  penetrating  ;  such  as,  althea,  camomile,  nitre, 
alkali,"  &c.  This  method,  however,  was  generally  reprobat- 
ed, in  the  commencement  of  inflammation.  When  neither 
of  ihese  plans  would  succeed,  then  the  matter  was  to  be  con- 
cocted, the  tumor  suppurated,  mundified,  deterged,  incarned, 
and  finally  cicatrized. 

Bleeding  was  directed  to  be  less  frequent  in  the  congestion 
than  in  the  fluxion  ;  but  then  the  purges  were  to  be  stronger, 

ed,  when  the  arm  or  shoulder  is  injured  ;  the  median  detracts  from  the  breast  or 
side  ;  the  basilic  from  the  belly,  and  the  veins  at  the  ankles  from  the  two  inferior 
extremities.    Vide  Phil.  Trans,  vol.  LXXIX. 

*  In  inflammation  of  the  throat,  forinstance,  blood  was  taken  from  the  lingual 
vein?. 


147 

and  given  with  a  more  liberal  hand.*     Along  with  the  ex 
hibition  of  purgatives,  the  hot  remedies,  called  discutients, 
were  to  be  applied  to  the  part  itself;  such  as,  thyme,  galba- 
num,  sal  ammoniac,  &c. 

At  last,  the  doctrine  of  fluxion  began  to  lose  ground,  and 
the  physicians  slowly  to  perceive,  that  their  boasted  theories 
of  derivation  and  revulsion  were  absolutely  incompatible  with 
the  true  history  of  the  circulation  of  the  blood.  The  cause 
of  inflammation  was  now  sought  for,  more  universally,  in  the 
part  itself,  and  obstruction  declared,  more  decidedly,  to  be 
the  parent  of  disease. 

It  was  the  opinion  of  Boerhaave,f  that  inflammation  was 
caused  by  an  obstruction  to  the  free  circulation  of  the  blood, 
in  the  minute  vessels;  and  this  obstruction,  he  supposed^ 
might  be  caused  by  heat,  diarrhoea,  too  copious  flow  of  urine, 
and  sweat,  or  whatever  could  dissipate  the  thinner  parts  of 
the  blood,  and  produce  a  thickness  or  viscidity  of  that  fluid. 
Where  this  lentor  did  not  exist  before  the  production  of  in- 
flammation,  he  imagined,  that  the  larger  globules  of  the  blood 
got  into  the  small  vessels,  and  thus  plugged  them  up.  When, 
for  instance,  the  perspiration  was  stopped,  the  fluid  being  re- 
tained, dilated  the  vessels,  and  allowed  some  of  these  mis- 
chievous globules  to  enter,  and  produce  a  more  permanent 
obstruction.  This  circumstance  was  termed  an  error  loci, 
and  was  one  of  the  chief  causes  assigned  for  inflammation. 
But  whether  the  obstruction  arose  from  the  viscidity  of  the 
blood,  or,  independently  of  it,  from  an  error  loci,  the  same 
effect  was  supposed  to  be  produced,  namely,  a  resistance  to 
the  circulation,  which,  of  course,  increased  it  in  the  other 
vessels,  proved  an  irritation  to  the  heart,  and  increased  the 


*  In  fluxions,  purging  was  considered  as  a  dubious  remedy,  at  least,  where  the 
liver  was  in  fault;  because  it  was  tliought  to  draw  all  the  foul  a"nd  noxious  mnt. 
ten  to  that  quarter. 

f  Aph.  375.  ef  » 


148 

force  or  attrition  of  the  blood,  in  that  part  of  the  vessel 
which  was  behind  the  obstruction ;  this,  again,  caused  heat 
and  pain,  whilst  the  accumulation  of  the  blood  produced  red- 
ness ;  which  three  symptoms  are  the  essence  of  the  disease. 
But,  besides  this  obstruction,  he  also  brought  into  account  an 
acrimonious  state  of  the  fluids  ;  and,  when  this  occurred,  re- 
solution was  out  of  the  question ;  nay,  if  the  acrimony  were 
great,  gangrene  was  almost  unavoidable.* 

The  viscidity  of  the  blood  cannot  be  admitted  as  the 
proximate  cause  of  inflammation ;  because  we  have  no  proof 
ihat  this  state  ever  exists ;  or,  granting  that  it  did,  it  would 
not  explain  the  phenomena.  In  inflammation,  the  blood,  so 
far  from  being  deranged  in  the  proportion  of  its  component 
parts,  or  from  one  portion  having  a  greater  quantity  of  coagu- 
lable  lymph  (which  alone  could  make  it  thicker)  than  another, 
seems  to  have  its  principles  more  intimately  united ;  for  it 
requires  a  longer  time  to  separate  them  by  coagulation  ;  and, 
therefore,  no  variation  can  take  place,  in  any  particular  part 
of  the  body.  If,  then,  a  viscidity  takes  place,  it  must  exist 
equally  in  every  portion  of  the  blood  ;  and,  if  so,  it  must  af- 
fect every  part  of  the  body  alike  ;  and,  therefore,  cannot  be 
supposed  to  produce  only  a  local  disease.  But,  granting  it 
to  be  possible  for  viscidity  to  induce  inflammation,  it  remains 
to  be  demonstrated,  hew  this  lentor  is  occasioned,  by  causes 
which  bring  on  inflammation  suddenly,  without  affording 
time  for  changes  of  the  fluids  to  take  place.  It  also  remains 
to  be  proved  by  experiments,  that  such  a  thickened  state  of 
the  blood  ever  does  exist,  either  in  infkrmmaiion,  or  in  any 
other  disease. 

With  regard  to  the  doctrine  of  error  loci,  or  of  red  glo- 
bules going  into  vessels  which  did  not  formerly  transmit  them, 
the  fact  must  be  admitted,  at  the  same  time  that  the  con- 

*  A ph.  383. 


149 

dusion  is  denied.  When  the  eye  becomes  inflamed,  the 
tunica  conjunctiva  is  seen,  with  its  vessels  full  of  red  blood, 
which,  in  health,  is  not  the  case ;  but  this  redness  never  ap- 
pears until  the  inflammation  has  commenced  ;  it  is  therefore 
to  be  considered  as  an  effect,  and  not  as  a  cause.  Nor  does 
this  error  loci  occasion  any  obstruction  in  these  vessels  ;  for, 
if  they  be  divided,  the  blood  flows  freely,  which  shows,  that 
they  are  large  enough  to  allow  of  an  easy  circulation,  a  cir- 
cumstance which  is  altogether  incompatible  with  the  notion 
of  obstruction  :  For,  were  this  obstruction  to  take  place,  the 
flow  of  blood  must  be  checked  ;  it  must  either  move  much 
more  slowly,  and,  therefore,  stimulate  less;  or,  it  must  take 
another  course  ;  for  it  is  well  known,  that,  whenever  a  vessel 
is  obstructed  by  pressure,  by  adhesion,  or  by  a  globule 
plugging  it  up,  that  less  blood  must  go  that  way,  and  more  by 
another  course  ;  the  consequence  of  which  is,  that  the  part 
will  rather  be  weakened  than  inflamed. 

As  for  the  supposition  of  the  co-operaticn  of  an  acrimony 
of  the  fluids,  it  may  be  sufficient  to  observe,  that  the  pro- 
portion of  the  saline  matter  of  the  blood  has  never  been  proved 
to  be  greater  in  this  than  in  any  other  state  of  the  body,  and 
that  the  very  idea  of  cacochymy  is  diametrically  opposite  to 
the  laws  of  the  living  system.  But  enough  has  been  former- 
ly said,  in  the  preliminary  dissertation,  concerning  the  lui- 
moural  pathology  ;  and  more  will  be  afterwards  adduced- 
The  subject  may,  therefore,  for  the  present,  be  dismissed. 

Professor  Vacca,*  was  likewise  of  opinion,  that  an  ob- 
struction to  the  motion  of  the  blood  was  the  cause  of  in- 
flammation ;  but  this  he  attributed,  not  to  lentor,  or  error 
loci,  but  to  a  debility  of  the  inflamed  part,  which  prevented 
it  from  propelling  the  blood  as  formerly,  and  produced  an  ac- 
cumulation of  it  in  the  weakened  vessels,  the  consequence  of 

*  Vacca  de  Inflate.  Morb.  &<•. 


V)0      ' 

wMch,  in  his  opinion,  was  a  species  of  combustion,  or  real  in 
flammaion.  He  begins  by  observing,  that  there  are  four 
principal  fluids  in  the  body  ;  the  blood,  the  lymph  or  serum, 
the  fat,  and  the  nervous  fluid.  The  lymph,  being  watery  > 
cannot  be  inflamed  or  burnt ;  the  blood  is  slightly  inflamma- 
ble ;  the  fat  is  altogether  so ;  but  the  nervous  fluid,  from  its 
volatility,  cannot  bear  enough  of  heat  to  inflame  it.  It  is 
also  laid  down  as  a  principle,  that  no  inflammation  can  take 
place  without  the  aid  and  operation  of  atmospheric  air,  which 
both  draws  inflammable  matter  to  the  part,  and  inflames  it. 
Without  fatty,  or  phlogistic  matter,  then,  and  air,  no  in- 
flammation can  take  place.  This  inflammation  is  begun  by 
the  accumulation  of  blood,  which  is  to  be  considered  as  a 
heated,  or  ignited  body.  The  accumulation  and  "  semistag- 
nation"  of  the  blood,  uniformly  depends  upon  a  weakness  of 
the  part,  either  real  or  absolute  ;  real,  when  its  power  is  po- 
sitively diminished ;  relative,  when  it  is  not  diminished,  but 
the  strength  of  the  rest  of  the  system  preternaturally  in- 
creased above  it.* 

In  consequence  of  this  weakness,  the  blood  not  only  moves 
more  slowly,  but  more  also  flows  in,  which  produces  a  swell- 
ing of  the  part.  This  is  farther  increased,  by  the  extrica- 
tion of  air  from  the  stagnant  matter,  in  consequence  of  the 
heat,  by  which  the  part  is  distended,  and  still  more  humour 
and  phlogistic  matter  is  allowed  to  flow  in. 

Upon  the  humoural  part  of  this  theory,  I  deem  it  to  be 
unnecessary  to  make  any  observation  ;  and,  upon  the  position, 
that  debility  of  the  inflamed  part  is  the  cause  of  inflamma- 
tion, I  think  it  sufficient  to  observe,  first,  that  many  of  the 


*  "  Inflammatio  cujusv  is  partis  human!  corporis,  numquamsit,  nisi  in  ipsa  parte 
sanguis  coacervetur,  et  fere  quie?eat." — "Coacervatio  et  semistagnatio  sanguinis, 
vrl  alius  humoris  corporis  humani,  in  quacumque  ipsius  corporis  parte  minime 
centingere  potest,  Fioe  ijrius  partis  absoluta,  vel  relativa  debilitate."  Vacca, 
p.  18-. 


151 

exciting  causes  evidently  have  no  tendency  to  weaken,  when 
they  induce  inflammation :  Heat,  for  instance,  frequently 
inflames  before  it  can  possibly  be  supposed  to  have  produced 
any  weakness.  Second,  all  the  symptoms  of  inflammation 
evince  an  increased  action.  Third,  bleeding,  and  other 
causes,  which  diminish  action,  cure  inflammation. 

Dr.  Cullcn  considers  the  proximate  cause  of  inflammation 
to  be  "  a  spasm  of  the  extreme  arteries,  supporting  an  in- 
creased action  in  the  course  of  them."  This  theory,  there- 
fore, differs  from  that  of  Dr.  Boerhaave  only  in  the  cause 
which  is  assigned  for  the  obstruction.  A  detection  of  the 
fallacy  of  the  one  supposition  will,  therefore,  be  sufficient  to 
disprove  both.  But,  as  Dr.  Cullen  was  a  man  who  formed 
no  opinion  without  a  plausible  reason,  it  will  be  proper  to  at- 
tend more  minutely  to  his  doctrine ;  and  this  is  very  plainly 
laid  down  in  the  two  hundred  and  forty-fourth  and  two  hun- 
dred and  forty-fifth  paragraphs  of  his  Outlines.  "  Some 
causes  of  inequality  (says  he)  in  the  distribution  of  the  blood, 
may  throw  an  unusual  quantity  of  it  upon  particular  vessels, 
to  which  it  must  necessarily  prove  a  stimulus.  But,  farther, 
it  is  probable,  that,  to  relieve  the  congestion,  the  vis  medica- 
trix  naturae  increases  still  more  the  action  of  these  vessels  ; 
and  which,  as  in  all  other  febrile  diseases,  it  affects,  by  the 
formation  of  a  spasm  on  their  extremities." — "  A  spasm  of 
the  extreme  arteries,  supporting  an  increased  action  in  the 
course  of  them,  may,  therefore,  be  considered  as  the  proxi- 
mate cause  of  inflammation  ;  at  least,  in  all  cases  not  arising 
from  direct  stimuli  applied ;  and,  even  in  this  case,  the  sti- 
muli may  be  supposed  to  produce  a  spasm  of  the  extreme 
vessels." 

These  paragraphs  contain  three  positions  ;  1st.  That  there 
is,  originally,  a  congestion,  or  accumulation  of  blood ;  2dly. 
That  this  is  removed  by  the  formation  of  a  spasm ;  3dly. 
That  this  spasm  is  the  work  of  the  vis  medicatrix  naturae. 


Iu2 

Upon  the  first  of  these  positions,  it  will  be  sufficient  to  re- 
mark, that  this  accumulation  of  blood  is  considered  as  the 
cause  of  inflammation,  and  not  as  an  effect ;  whereas,  it  is 
evident,  that  it  exists  only  as  a  symptom.     When,  for  in- 
stance, we  apply  heat,  a  blister,  or  any  acrid  substance,  to 
the  surface,  the  part  is  stimulated,  that  is  to  say,  the  action 
of  its  nerves  is  increased,  which   must,    consequently,   in- 
crease the  action  of  its  vessels,  and,  of  necessity,  the  quan- 
tity of  blood.     But,  most  assuredly,  this  increased  quantity 
of  blood  is  not  the  primary  cause  of  inflammation ;  it  is  the 
consequente  of  an  increased   action  of  the  blood-vessels, 
which,  again,  is  meiely  an  effect  of  the  increased  nervous  ac- 
tion.    The  first   position  is,  therefore,  erroneous  ;  for  this 
accumulation  of  blood  is  not  an  original,  or  primary  cause, 
but  depends  upon  a  disease  already  induced.     At  the  same 
time,  it  is  certain,  that  this  increased  quantity  of  a  stimulus 
must  react  on  the  nerve,  and  augment  still  farther  its  action, 
and,  therefore,  increase  or  keep  up  the  inflammation  already 
induced. 

The  second  position  takes  for  granted  that  the  first  is  es- 
tablished, and  that  the  congestion  is  to  be  removed  by  the 
formation  of  a  spasm  ;  or,  in  other  words,  that  the  accumu- 
lated quantity  of  blood  is  to  be  propelled,  or  dismissed,  by 
rendering  the  extremity  of  the  passage  narrower,  and  the 
circulation  more  difficult,  which  is  a  contradiction  in  terms. 
The  obvious  effect  of  this  constriction  must  be,  to  destroy 
the  free  communication  of  the  artery  with  its  returning  vein. 
The  blood  already  in  the  part  must  stagnate,  and  become 
veinous,  or  it  must  escape  by  a  retrograde  motion,  the  exist- 
ence of  which,  to  any  extent,  is  not  proved.  Whenever  a 
vessel  is  constricted,  either  by  a  ligature,  or  any  other  cause, 
we  uniformly  find,  that  the  course  of  the  circulation  is  alter- 
ed, more  being  sent  through  the  branches  of  ihe  artery 
coming  off  above  the  obstruction  ;  therefore;,  the  part  direct- 


153 

\y  supplied  by  the  obliterated  or  constricted  artery  must,  for 
a  time,  be  weakened.  It  may  be  said,  that  though  the  part 
supplied  by  the  obstructed  vessel  may  be  debilitated,  yet 
those  parts  which,  in  consequence  of  this  obstruction,  must 
receive  mote  blood,  will  be  inflamed :  But  we  daily  find,  that, 
even  tying  a  large  vessel,  does  not  of  itself  produce  this  dis- 
ease ;  how  much  less,  then,  will  constricting  the  extremities 
of  a  few  twigs  be  capable  of  affecting  it  I  The  uniform 
effect  of  obstruction  must  be,  to  retard  the  circulation,  and 
produce  torpor,  circumstances  altogether  incompatible  with 
the  existence  of  inflammation,  which  implies  more  powerful 
contractions,  and  a  more  complete  and  forcible  circulation. 
Phlegmon  is  also  attended  with  an  effusion  into  the  cellular 
substance  from  the  extremities  of  the  arteries,  a  circum- 
stance not  easily  explained  upon  the  principle  of  obstructed 
circulation. 

The  third  position  is,  that  the  formation  of  the  spasm  is 
the  work  of  the  vis  medicatrix  naturae ;  but,  having  denied 
the  truth  of  the  former  position,  it  follows,  that  the  present 
supposition  requires  no  answer  ;  because  it  is  unnecessary  to 
show  the  absence,  or  insufficiency  of  a  cause,  if  the  exist- 
ence of  the  effect  be  disproved.  Still  it  may  not  be  impro- 
per to  remark,  that  the  spasm  induced,  or  the  agency  of  the 
vis  medicatrix,  is  considered  as  producing  the  most  serious 
part  of  the  disease,  ll  is  not  the  congestion  of  blood  which 
is  held  out  as  the  proximate  cause,  but  the  attempt  which 
the  healing,  or  preserving  power  of  nature  makes  to  get  quit 
of  it.  The  blood  is  here  considered  as  an  exciting  cause, 
but  is  by  no  means  understood  to  operate  directly ;  on  the 
contrary,  it  only  gives  notice  to  the  preserving  power,  which, 
in  order  to  get  rid  of  it,  occasions  a  spasm,  followed  by  dis- 
ease. Nay,  so  far  does  Do;tor  Cullen  carry  his  theory  of 
spasms,  and  preserving  powers  of  nature,  that  he  imagines, 
Jhat  even  siimulan's,  opevmijpg  direct ly  on  a  part,  such  a.* 
vol.   i.  r 


154 

cantharides,  mezereon,  or  red  precipitate,  induce  inflamma- 
tion, in  the  same  round-about  way.  But,  by  a  very  little  at- 
tention, we  shall  find,  that  all  these  agems  operate  primarily 
on  ihe  nerves,  increasing  their  action,  and  changing  it,  and, 
of  consequence,  the  action  of  the  vessels  supplied  by  them. 
This  action,  however,  is  very  different  indeed  from  spasm  or 
obstruction. 

The  celebrated  John  Brown  taught  a  doctrine,  which  was 
new  to  the  Edinburgh  Professors,  and  diametrically  opposite 
to  the  theories  which  were  maintained  in  their  schools.  Dis- 
eases, according  to  his  system,  were  all  divided  into  two 
classes,  those  which  consisted  in  a  morbid  degree  of  strength, 
and  those  produced  by  the  varied  degrees  of  weakness. 
This  theory  was,  to  appearance,  simple  ;  it  was  built  entirely 
on  the  sthenic  and  asthenic  diathesis,  and  admitted  of  no  in- 
tricate actions  of  the  living  system.  Little  labour,  then,  was 
demanded  of  the  student,  and  not  much  reflection  of  the 
practitioners.  It  was  addressed,  in  a  peculiar  manner,  to 
the  indolent  dispositions  of  mankind,  and,  therefore,  met  wi'.h 
considerable  su  ess,  which  perhaps  was  not  a  little  inc* eased 
by    he  plea  of  persecution. 

Inflammation  was  said,  by  Dr.  Brown,  to  depend  either 
upon  'oo  inu  h  strength,  or  too  much  weakness.  In  the  first 
case,  the  vessels  contracted  with  great  force,  and  pushed  on 
theii  contents  with  fury.  In  ihe  second,  the  vessels  were 
too  weak  o  arry  on  the  circulation  properly,  but  relaxed 
freely,  to  allow  as  much  blood  to  be  pushed  into  them,  as  the 
vis  a  te  go  was  able  io  do.  This,  however,  is  by  much  too 
mechanic  al  an  idea,  and  cannot  be  admitted,  now  that  the 
reasonings  of  ihe  mathematical  physicians  have  sunk  into 
oblivion.  The  whole  se.  ies  of  symptoms,  together  with  the 
circumstances  which  f  equenJy  atSend  the  accession  of  in- 
flamma  ion,  as  well  as  its  ending  in  other  actions,  disprove 
the  supposition.     If  inuammation  depended,   in   one   case, 


155 

upon  too  much  contractile  force  of  the  vessels,  and,  in 
another,  upon  their  relaxation,  then,  in  order  to  give  consis- 
tency to  the  doctrine,  it  ought  to  be  admitted,  that  secre'ions 
were  formed  by  filtration;  and  that  these  slates  of  :he  ves- 
sels, after  a  certain  duration,  came  to  strain  through  pus. 
Mere  increase  of  streng:h,  excitement,  or  contractile  power, 
without  a  change  of  action,  never  can  produce  the  pheno- 
mena of  inflammation,  nor  account  for  adhesion,  suppuration, 
or  ulceration.  Partial  debility  of  the  vessels  cannot,  on  the 
other  hand,  produce  the  second  species  of  inflammation  :  be- 
cause this  debility  should,  at  the  very  utmost,  produce  only 
a  slower  circulation,  and  not  an  inflammatory  action;  neither 
ought  it  to  be  the  cause  of  swelling  and  turgidity  of  the  arte- 
ries, by  allowing  more  than  the  due  quantity  of  blood  to  be 
forced  into  them;  for  the  quantity  of  blood  in  a  vessel,  does 
not  depend  upon  the  proportion  betwixt  its  contractile  power, 
and  the  propelling  power  of  the  rest  of  the  system,  but  upon 
its  own  action  entirely  ;  otherwise,  we  should  find  paralytic 
limbs  always  turgid  with  blood.  Farther,  the  Brownonian 
theory  will  not  explain  the  phenomena  of  inflammation  in 
weakened  parts  ;  for  here  there  is  a  great  action,  with  little 
power ;  and  hence  the  part  is  almost  immediately  killed. 
The  progress  of  this  is  stopped  by  bark  and  opium,  with 
proper  local  applications.  From  the  treatment,  then,  the 
Brownonian  would  say,  that  the  inflammation  depended  upon 
weakness.  But  will  simple  relaxation  explain  why  death  should 
so  rapidly  take  place  ? 

According  to  Mr.  Hunter,  "  inflammation  is  to  be  consi- 
dered only  as  a  disturbed  state  of  parts,  which  requires  a  new, 
but  salutary  mode  of  action,  to  restore  them  to  that  state, 
wherein  a  natural  mode  of  action  alone  is  necessary.  F  om 
such  a  view  of  the  subject,  therefore,  inflammation,  in  itself, 
is  not  to  be  considered  as  a  disease,  but  as  a  salutary  opera- 


156 

rion,  consequent  either  to  some  violence,  or  some  disease/"1 
"  The  act  of  inflammation  is  to  be  considered,  as  an  increas- 
ed action  of  .he  vessels,"f  which  at  first  consist  simply  in 
"  an  increase  or  distention  beyond  their  nalural  size." J  This 
increase  seems  to  depend npon  a  diminution  of  ihe  muscular 
power  of  the  vessels,  at  the  same  time  that  the  "  elastic  pow- 
er of  the  artery  must  be  dilated  in  the  same  proportion."§ 
This  is,  therefore,  something  more  than  simply  a  common  re- 
laxa'ion  ;  we  must  suppose  it  an  action  in  the  parts,  to  pro- 
duce  an  increase  of  size,  to  answer  particular  purposes  ;  and 
this  I  should  call  an  action  of  dilatation."  The  whole  is  to  be 
considered,  "  as  a  necessary  operation  of  nature. "l|  Owing 
to  this  dilatation,  there  is  a  greater  quantity  of  blood  circulat- 
ing in  the  part,  "  which  is  according  to  the  common  rules  of 
the  animal  economy ;  for,  whenever  a  part  has  raoi  e  to  do, 
than  simply  to  support  itself,  the  blood  is  there  collected  in 
larger  quantity."'**  The  swelling  is  produced  by  an  extra- 
vasation of  coagulable  lymph,  with  some  serum  ;  but  this 
lymph  differs  from  common  lymph,  in  consequence  of  pass- 
ing through  inflamed  vessels.ff  It  is  this  lymph  which  be- 
comes the  uniting  medium  of  inflamed  parts  ;  vessels  shoot 
into  it  ;  and  it  has  even  the  power  of  becoming  vascular  it- 
self. Xt  The  pain  proceeds  from  spasm. 55  The  redness  is 
produced,  either  by  the  arteries  being  more  dilated  than  the 
veins,  or  because  the  blood  is  not  changed  in  the  veins. |||j 
"When  a  part  cannot  be  restored  to  health,  after  injury,  by 
inflammation  alone,  or  by  adhesion,  then  suppuration,  as  a  pre- 
paratory step  to  the  formation  of  granulations,  and  the  conse- 
quent restoration  of  the  part,  takes  place.***     The  vessels 


*  Hunter  on  Inflammation,  p.  '219. 

■f     P.  278.  \  P.  279.  }  P.  282. 

i|  P.  282.  **  P.  280.  ft  P.  311. 

U  P.  309.  {$  P.386  |M  P381 

"*  P.  371. 


157 

are  nearly  in  the  same  slate  as  in  inflammation ;  but  they  are 
more  quiescent,  and  have  acquired  a  new  mode  of  action.* 

Inflammation,  according  to  this,  as  well  as  some  other  doc- 
trines, is  to  be  considered,  not  as  a  disease,  but  as  a  salutary 
operation  of  some  wise  and  provident  power,  performed  in  or- 
der to  rid  the  system  of  some  impending  evil,  or  to  renew  a 
structure,  which  could  not  otherwise  be  restored.  But  I  hold 
it  to  be  an  established  point,  that  there  is  no  supposition  more 
directly  contrary  to  true  philosophy,  or  to  ihe  principles 
which  reason  teaches,  than  the  opinion,  that  certain  events 
take  place,  merely  because  these  evenis  are  useful;  as,  for 
instance,  the  coagulation  of  the  blood  in  mortification  ;f 
whether  we  refer  these  events  to  the  agency  of  some  peculiar 
power  called  nature,  or  to  ihe  mo^e  extensive  operation  of 
some  general  principle. 

Inflammation  is,  in  many  cases,  so  far  from  being  a  "  saluta- 
ry mode  of  aciion,"  that,  in  a  great  majority  of  instances,  it  is 
a  most  dangerous  and  a  most  troublesome  disease  ;  and  I  shall 
presen.ly  endeavour  to  show,  that  it  is  not  though  the  inter- 
ference of  this  action,  that  divided  parts  unite  ;  but  that,  on 
the  contrary,  whenever  the  action  becomes  inflammatory,  that 
then  no  union  and  no  restoration  take  place,  but  the  sides  re- 
main separa'.e.  until  the  disease  subside. 

Inflammation  is  considered  as  "  an  increased  action  of  the 
vessels,"  which  chiefly  consists  in  a  greater  degree  of  dilata- 
tion, the  power  of  muscular  contraction  seeming  to  give  way. 
This  allows  more  blood  to  enter  ;  which  greater  quantity  of 
blood  is  not  considered  as  a  symptom  or  part  of  ihe  disease, 


*  Hunter  on  Inflammation,  P.  372. 

f  "  For  this  purpose,  (coagulation,)  it  (blood)  requires  rest,  either  by  extrava- 
sation, or  being  retained  in  the  vessels,  till  the  utility  of  circulation  is  lost,  or  till 
it  can  answer  some  good  purpose  by  its  coagulation,  as  in  mortification."  Hunter 
onlhr  Shod,  kc.  p.  86. 


158 

but  as  one  of  the  contrivances  of  nature,  the  part  having  more 
to  do  than  simply  to  support  itself. 

How  far  the  loss  or  diminution  of  muscular  power  will  ac- 
count for  this  dilatation,  will  afterwards  be  examined.  Here 
I  shall  only  observe,  that  the  doctrine  of  ihe  simple  increase 
of  action,  (circulating  action,)  in  a  vessel,  or  simple  dilataiion, 
never  can  explain  the  production  of  inflammation,  which  is  to 
be  considered  as  a  state  which  is  new  and  diseased,  and  to- 
tally different,  both  in  its  na'ure  and  consequences,  from  he 
condition  which  subsists  in  health.  The  other  parts  of  the 
theory  will  come  afterwards  to  be  consideied. 

According  to  Dr.  Darwin,  when  any  part  is  excited  "  into 
such  violent  motion,  that  a  quantity  of  pleasurable  or  painful 
sensation  is  produced,  it  frequently  happens,  bm  not  always, 
that  new  motions  of  the  affected  organ  a;e  genera  ed,  in  conse- 
quence of  the  pain  or  pleasure,  which  are  termed  inflamma- 
tion. These  new  motions  aie  of  a  peculiar  kind,  tending  to 
distend  the  old,  and  to  produce  new  fibres,  and  thence  to  elon- 
gate the  straight  mus  les,  which  serve  lo.  o-mo. ion,  aud  to 
form  new  vessels,  at  the  ext- entities  or  sides  of  .he  vas,  ular 
muscles."*  Upon  this  theory  I  shall  only  make  three  ob- 
servations: First,  the  effect  of  inflammation  or  sensation,  is 
considered  as  its  cause  :  Second,  we  very  frequently  have 
highly  pleasurable  sensa.ions,  or  great  pain,  ex  iied  in  a  part, 
without  any  production  of  inflammation  ;  theiefo  e,  if  the  sup- 
posed causes  of  inflammation  have  existed,  and  r.o  cir  uni- 
stances  have  occurred  :  apable  of  counte  acting  their  ope  a- 
tion,  it  will  follow,  that  these  causes  are  not  real,  but  imagi  a- 
ry  :  Third,  the  motions  which  are  supposed  ,o  ake  pla  e, 
are  not  sufficient  to  explain  the  phenomena  of  he  disease. 

From  an  attentive  examination  of  the  ope  at  ion  of  <he  ex- 
citing cause  of  inflammation,  and  from  a  view  of  its  difte.ent 

*  Zoonomia,  Vol.  I.  p.  395, 396; 


159 

symptoms,  we  canned  admit  the  proximate  cause  to  consist 
in  vis  idi  y,  or  e;  o  loci  of  the  blood,  or  spasm,  or  simple  in- 
ci  se  of  s  heni"  or  as  henic  diathesis,  or  actions  of  dilata- 
tio..,  o  increased  sensation,  but  must,  upon  the  principles 
al  eady  lasd  down,  consider  it  as  a  new  and  distinct  action  of 
the  living  system.  When  this  action  is  uncombined  with  any 
othc  morbid  condition,  the  disease  is-simple  inflammation  ; 
bu  when  to  this  another  action  is  united,  or  when  the  inflam- 
matory action  is  modified,  the  disease  is  no  longer  simple,  but 
specific  inflammation. 

In  examining  new  actions,  we  find  it  to  be  of  use  to  compare 
them  with  those  which  they  resemble  most,  and  with  which 
we  are  better  acquainted.  It  has  been  already  mentioned, 
that  whatever  tended  greatly  or  suddenly  to  increase  the  na- 
tural action  of  a  part,  changed  it,  and  produced,  inflammation. 
This  we  learn,  from  examining  the  exciting  causes  of  this  dis- 
ease ;  and,  by  analysis,  we  find  some  similarity  betwixt  this 
and   he  natural  action. 

The  esseuiial  symptoms  of  inflammation,  are  redness, 
swelling,  heat,  and  pain,  which  in  some  instances,  are  preced- 
ed, and  in  others,  followed  by  a  general  disease.  These 
symptoms,  when  taken  together,  differ  very  materially  from 
the  natural  state  and  condition  of  the  part ;  and,  therefore, 
although  they  may  have  been  produced  by  causes  which 
tend  to  inc  ease  the  natural  action,  yet  we  must  conside-  this 
action  as  materially  changed,  in  consequence  of  the  morbid 
inc; ease. 

Akhough  this  be  the  case,  and  although  many  new  actions 
do  not  admit  of  analysis,  yet  the  different  symptoms  of  in- 
flammation may  be  explained,  or  the  action  analysed  ;  and  this 
J  shall  proceed  now  to  do. 


no 


Of  the  Ratio  Symptomatum. 

Redness. — The  redness  of  the  inflamed  part,  is  evidently 
owing  to  the  presence  of  a  greater  quantity  of  blood  than 
usual ;  and  this  augmentation  seems  to  be  produced,  both  by 
the  vessels  whkh  formerly  conveyed  the  blood  being  more 
distended,  and  also,  by  the  enlargement  of  the  small  vessels, 
which  formerly  contained  only  lymph,  but  which  now  receive 
red  blood.  It  is  the  enlagement  of  these  small  vessels, 
which  have  made  some  suppose,  that  new  vessels  were  form- 
ed by  inflammation ;  a  supposition  which  is  evidently  con- 
tradicted, by  observing,  that  heat,  and  many  other  causes  of 
inflammation,  operate  so  quickly,  that  no  new  vessel  can  have 
time  to  be  formed ;  and  yet  the  redness  is  as  great,  and  the 
inflammation  as  perfect  in  a  minute,  as  in  an  hour  or  a  day, 
after  their  application.  The  formation  of  a  perfect  and  regu- 
larly organised  substance,  by  a  strongly  diseased  action,  is 
likewise  incompatible  with  the  usual  laws  of  the  animal  eco- 
nomy. 

There  is,  likewise,  another  cause,  which  will  co-operate 
with  this,  in  producing  ihat  bright  redness  which  attends  many 
inflammations,  namely,  that  owing  to  the  diseased  action,  the 
arterial  blood  is  not  so  thoroughly  converted  into  veinous,  as 
in  healih.*  Another  consequence  of  which,  as  has  been  for- 
merly mentioned,  is,  that  less  life  or  energy  is  yielded  to  the 
part,  and  therefore  it  sutlers  more  than  it  otherwise  would  do. 

As  the  vessels  are  supposed  to  act  more  powerfully  in  in- 
flammation, it  has  been  thought,  that  they  ought  to  contract 
to  a  greater  degree  ;  and,  therefore,  ought  rather  to  allow  less 


*  This  fact  has  been  mentioned  by  Mr.  Hunter  ;  but  he  accounts  for  it  upon 
the  principle  of  its  motion  being  accelerated,  which  is  certainly  a  mistaken  vier 
of  the  subject.     P.  281. 


1G1 

Wood  than  formerly  to  enter,  than  to  become  turgid.  Borne 
have,  therefore,  supposed,  that  inflammation  was  uniformly 
produced  by  weakness  of  the  part  ;  and  this  idea  is,  in  one 
view,  adopted  by  Mr.  Hunter,  who  supposes,  that  the  mus- 
cular power  of  the  vessels  is  diminished  in  inflammation, 
which,  therefore,  can  be  more  fuliy  dilated.  But,  certainly, 
the  continuation  of  the  circulation,  implies  a  continuation  of 
the  powers  which  carry  it  on.  Mr.  Hunter  even  allows,  iliat 
the  blood  circulates  faster  than  usual,  which  cannot  well  hap- 
pen, if  the  muscular  power  gives  way.  The  blood  is  carried 
from  the  heart  along  all  (he  vessels;  first,  by  the  percussive 
force  of  the  heart,  and  nest,  by  the  contractions  of  the  arte- 
ries, which  co-operate  with  the  original  projection.  Without 
muscular  contraction  in  every  part  of  the  vessels,  we  must  either 
suppose  the  heart  to  possess  a  force  beyond  all  belief,  or  we 
must  allow  the  circulation  to  proceed  only  a  very  li;tle  way  ; 
for  the  amplitude  of  a  projected  body  is  always  as  the  square 
of  the  impetus.  Were  the  arteries  only  elastic,  they  could 
only  react  on  the  blood,  and  propel  it  onward,  in  a  degree 
proportioned  to  the  original  action  of  the  heart,  and,  at  every 
inch,  the  velocity  must  become  less,  because  the  communica- 
ted force  must  be  diminishing.  Mr.  Hunter,  who  allows 
both  muscularity  and  elasticity  to  the  arteries,  admits,  that 
the  elasticity  diminishes  with  the  size,  whilst  the  muscular 
power  increases  as  the  other  diminishes.  If,  then,  the  muscu- 
lar  coat  of  the  extreme  vessels  be  destroyed  or  weakened, 
then  the  circulation  must  be  stopped,  and  the  part  become 
to'-pid,  instead  of  in  (lamed,  because  the;e  is  little  or  no  elas- 
ticity to  assist  the  circulation.  Mr.  Hunte  likewise  suppo- 
ses, that,  in  inflammation,  "  the  elastic  power  must  be  dilated  ;" 
by  which,  I  suppose,  he  means  the  elastic:  coat.  This  coat, 
granting  it  to  exist  in  the  minule  vessels,  must  then,  by  this 
dilatation  or  over-stretching, be  deprived  of  i?s  fela'siic  proper- 

VOL.    It  x 


162 

ties,  and,  therefore,  the  circulating  power  of  the  artery  be 
still  more  destroyed. 

Some,  who  have  had  recourse  to  the  supposition  of  weak- 
ness producing  inflammation,  have  conjectured,  that  the 
power  or  force  of  the  upper  part  of  the  artery  was  increased, 
in  proportion  to  the  weakness  of  the  extremity ;  and,  there- 
fore, that,  by  the  vis  a  tergo,  the  circulation  was  carried  on, 
and  the  part  likewise  became  more  turgid.  But  this  goes 
upon  the  supposition,  that  the  exciting  causes  of  inflammation 
can  always  act  more  upon  parts  at  a  distance,  than  upon  the 
inflamed  part ;  and  reduces  the  whole  nearly  to  the  old  doc- 
trine, of  a  part  sending  and  a  part  receiving. 

It  must  then  be  evident,  that  the  muscular  power  of  the 
artery  continues  strong  and  vigorous,  and  that  the  contrac- 
tions are  more  forcible.  The  dilatation  of  the  artery  is  pro- 
portioned to  the  contraction;  for,  unless  in  spasmodic  dis- 
eases, the  two  properties  of  a  muscle,  contraction  and  dila- 
tation, balance  each  other.  * 

Swelling. — The  swelling  of  an  inflamed  part  may  be  as- 
cribed to  two  causes  ;  1st.  To  the  increased  quantity  of 
blood  in  the  vessels  ;  2d.  To  the  deposition  of  new  matter. 
As  the  first  of  these  has  been  already  noticed,  I  shall  only 
here  attend  to  the  second. 

In  every  part  of  the  body,  there  are  two  sets  of  vessels, 
(though  many,  for  particular  purposes,  have  more  :)  The 
one  set  secretes  the  matter  which  forms  the  parts,  or  deposits 
new  organic   particlesf   as  the  old  ones  are  absorbed  ;  the 


*  It  may  perhaps  be  said,  that  as  muscles,  when  iuflamed,  become  rigid,  so  the 
muscular  power  of  the  arteries,  in  inflammation,  ought  to  be  diminished.  But  it 
is  to  be  remembered,  that  the  state  of  the  vessels,  and  the  state  of  the  inflamed 
parts,  are  not  exactly  similar,  and  that  the  same  effects  are  not  produced  in  each. 
This  must  be  evident.  In  the  same  way,  the  state  of  the  vessels  in  an  ulcer,  and 
the  state  of  the  ulcer,  or  the  condition  of  the  vessels  in  any  gland,  and  the  state 
of  the  gland  itself,  are  distinct  in  their  effects  and  phenomena. 

t  By  organic  particles,  I  understand  matter  secreted  or  deposited  in  an  organi- 
sed state,  so  as  to  repair  the  waste  of  the  body.    By  the  same  term,  the  Commie 


i6a 

other  excretes  a  particular  fluid  into  the  interstices,  betwixt 
the  different  organic  particles,  in  order  to  preserve  the  ne- 
cessary degree  of  softness  and  mobility.*  Now,  it  must  be 
evident,  that  if  the  action  of  a  part  be  changed,  the  functions 
of  the  part,  and  its  secretions,  must  also  be  more  or  less  af- 
fected. 

In  inflammation,  the  action  is  not  only  increased,  but 
changed  ;  the  secretions,  therefore,  are  also  changed,  and  in 
part  increased. 

The  interstitial  fluid  (or  the  fluid  which  softens  the  parts) 
is  increased  in  quantity,  but  it  is  also  different  from  what  it 
was  in  health ;  It  is  less  perfectly  prepared,  (if  by  perfection 
we  mean  the  state  which  was  originally  intended,)  and  ap- 
proaches nearer  to  the  nature  of  the  lymph  or  serum.  All 
the  secretions  are  formed  from  the  blood ;  and,  therefore,  the 
less  perfectly  that  they  are  formed,  the  nearer  must  they  ap- 
proach to  the  nature  of  the  fluid  from  which  they  derive 
their  origin. 

The  same  cause  which  affects  the  production  of  the  in- 
terstitial fluid,  must  likewise,  in  a  certain  degree,  affect  the 
formation  of  the  new  or  organic  particles  of  the  part.  These, 
in  inflammation,  will  be  deposited,  like  the  interstitial  fluid, 
in  greater  quantity,  but  they  will  likewise  be  less  perfect  ; 
for  both  the  perfection  and  the  longevity  of  the  particles  de- 
pends upon  the  arteries  performing  their  functions  regularly 
and  slowly. 

The  swelling,  then,  depends,  1st.  Upon  the  presence  of 
a  greater  quantity  of  blood  than  usual ;  2dly.  Upon  the  in- 
crease and  change  of  the  interstitial  fluid  ;  and,  3dly.  Upon 


de  Buffon  understands  molecules,  which  exist  every  where  in  the  3ame  form,  and 
do  not  receive  their  organization  at  the  part  which  they  are  to  join. 

*  This  fluid  is  even  to  be  found  betwixt  the  particles  of  bone;  but  it  differs  in 
them  from  the  fluid  which  eoftens  mufcles,  and  this  again  from  tti3t  whirU  be- 
'ongs  to  the  brain,  4"C-- 


164. 

lire  deposition  of  more  organic  particles,  in  an  imperfect 
staie.*  The  second  cause  operates  much  more  than  the 
other  two;  for  where  there  is  little  interstitial  fluid,  the 
swelling  is  less. 

Mr.  Hunter  supposes,  that  the  swelling  is  chiefly  produ- 
ced by  the  extravasation  of  coagulable  lymph,  which  under- 
goes some  changes,  by  passing  through  inflamed  vessels  ;  and 
that  -his  change  "  obliges  it  to  coagulate"  sooner  than  it 
otherwise  would  do-t  But  this  operation,  as  he  himseif  ac- 
knowledges, should  rather  retard  the  coagulation,  than  acce- 
lerate it. 

Pair.. — In  the  preliminary  dissertation,^,  it  was  mentioned, 
that  every  new  or  imperfect  action  is  productive  of  sensation 
in  the  mind,j|  and  ii  is  upon  this  principle,  that  we  are  to  ac- 
count for  the  pain  which  attends  inflammation.  The  more 
violent  that  the  inflammatory  action  is,  compared  to  the  pow- 
er of  the  pari,  or  its  previous  state  of  action,  the  more  acute 
is  the  pain.  When  inflammation  takes  place  in  a  part,  whose 
action  naturally  is  small,  such  as  cartilages  and  bones,  or 
whose  action,  owing  to  the  operation  of  other  causes,  ought 
to  be  very  low,  as,  for  instance,  parts  which  have  been 
weakened  by  cold,  then  the  pain  is  very  violent.  The  pain 
is  likewise  extremely  acute,  when  parts  are  inflamed,  which, 
in  health,  are  very  sensible.*^     Hence,  inflammation  of  the 


*  Owing  to  this  cause,  and  to  the  greater  thickness  of  the  interstitial  fluid,  the 
part  feels  hard. 

Hunter  on  Inflammation,  p.  311. 

|   1'  c  'iiuinary  Dissertation,  p.  125. 

i|  !;i  some  rare  instances,  the  change  of  action  does  not  produce  sensation,  or  at 
least,  the  sensation  does  not  amount  to  pain.  Dissection  proves,  that,  in  certain 
cases,  inflammation  has  existed,  and  lias  produced  suppuration,  without  giving  any 

■  >  p  uuful  sensation  to  the  patient. 

.  hat  i^-  to  say,  parts  which  have  action  easily  excited  in  them.  Some  parts 
have  their  action  increased  slowly,  and  %vilh  difficulty,  such  as  tendons,  bones, 
dec.  which  ma j  be  torn  or  broken  without  much  pain,  until  the  inflammatory  ac- 
tion bi?  slowly  induced,  and  then  the  sensation  is  acute.    If  parts,  whose  action  >* 


I(x3 

intestines  is  attended  with  violent  pain.  In  general,  the 
pain,  in  simple  inflammation,  is  greatest  dining  the  diastole  of 
the  artery. 

Some  ascribed  the  pain  to  the  mechanical  cause  of  disten- 
sion ;  but  we  must  ascribe  it  rather  to  the  peculiar  condition 
of  the  nerves,  or  their  state  of  acting  ;  because,  otherwise, 
we  should  find  the  pain  to  be  in  proportion  to  the  degree  of 
distension,  which  is  not  the  case.  Even  the  pulsatory  fee?, 
which  attends  inflammation,  is  not  entirely  dependent  upon 
simple  distension  and  contraction,  but  upon  the  peculiarity 
of  the  action ;  for,  in  some  species  of  inflammation,  that  is  to 
say,  some  modifications  of  the  inflammatory  action,  this  sen- 
sation is  not  produced. 

Heat. — Some  have  explained  the  production  of  animal 
heat  entirely  on  mechanical  or  chemical  principles,  and  have 
too  much  overlooked  the  agency  of  the  living  principle  : 
But,  whatever  means  may  be  employed  for  this  purpose,  we 
must  acknowledge  them  to  be  entirely  dependent  on  the  ac- 
tions of  life.  Common  matter  is  capable  of  existing,  with- 
out the  aid  of  other  matter  ;  but  animals  and  vegetables, 
which  exhibit  move  varied  phenomena,  and  perform  more  nu- 
merous actions,  depend  upon  other  substances  for  their 
growth  and  support,  and  become  afterwards,  in  their  turn, 
subservient  to  the  necessities  of  other  individuals  :  They  re- 
ceive their  increase  from  the  conversion  of  other  mailers  in- 
to a  part  of  themselves,  and  have  thfcir  life  renewed,  by 
changing  the  life  of  these  matters  into  their  own.  Keat  is 
likewise  a  principle,  which  is  necessary  to  their  existence  ; 
and  this  also  they  derive  from  without,  by  processes  which 
depend  upon  the  presence  of  life.  During  respiration,  the 
air,  which  is  combined  with  the  blood,  and  with  some  of  the 


naturally  low,  could  have  it  easily  and  quickly  increased,  they  would  become 
diseased  from  very  trifling  causes;  because  these  would  readily  induce  an  actios 
much  greater  than  the  natural  or  previous  action  of  the  part. 


166 

substances  which  it  contains,  gives  out  part  of  its  heat  to  the 
arterial  blood,  which  unites  with  it,  and  from  which  it  is  again 
separated  by  the  action  of  the  living  principle,  in  a  quantity- 
proportioned  to  the  degree  or  extent  of  the  action  in 
general. 

Those  actions  which,  although  different  from  the  natural 
one,  do  not  rise  in  degree  or  violence  beyond  it,  produce 
Iiitle  or  no  increased  quantity  of  heat.  Those  actions  which 
sink  below  this  medium,  produce  less  heat,  and  those  which 
rise  beyond  it,  more,  than  is  natural.*  The  production  of 
heat  is  not  exactly  on  the  same  footing  with  other  secretions, 
which  depend  not  so  much  on  the  degree,  as  on  the  peculiar 
nature  of  the  action ;  for  this  being  a  simple  substance,  can- 
not be  changed  by  the  change  of  action,  but  can  only  be  af- 
fected, with  regard  to  quantity,  by  the  degree  of  action  in 
the  vessels.f 

The  most  current  opinion,  on  this  subject,  is,  that  the  pro- 
duction of  animal  heat,  depends  upon  the  difference  in  the 
capacity  of  arterial  and  veinous  blood,  for  combining  with 
heat :  That,  in  the  extreme  vessels,  the  arterial  blood  is  com- 
bined with  certain  substances,  in  consequence  of  which  its 
capacity  is  diminished,  and  heat  is  given  out.  On  the  other 
hand,  when  veinous  blood  is  freed  from  these  substances  in 
the  lungs,  its  capacity  is  increased,  and  the  heat,  which  is 
given  out  by  the  decomposition  of  the  air  which  we  inspire, 
is  absorbed.  But,  granting  all  these  facts  to  be  proved,  it 
still  must  be  admitted  by  every  one  who  reasons  on  the  sub 
ject,  that  these  changes  cannot  take  place  spontaneously,  or 
of  themselves,  but  must  be  dependent  upon  the  operations  of 

*  By  low  or  violent  action,  I  mean  the  state  of  action,  or  its  degree,  consider- 
ed relatively  with  regard  to  the  power  of  the  part,  or  to  the  proportion  which 
ought  to  subsist  betwixt  action  and  energy. 

t  It  is  chiefly  at  the  surface,  that  the  action  produces  a  variation  in  the  degre* 
*f  actual  heat. 


167 

the  nervous  energy.  It  will,  then,  be  nearer  the  truth,  if 
we  consider  these  changes  rather  as  effects  of  the  general 
operatiou  which  produces  heat,  than  as  direct  causes  upon 
which  this  production  depends.  The  generation  of  heat  in 
an  animal,  is  truly  a  secretosy  process,  as  much  as  the  forma- 
tion of  bile  or  gastric  juice,  there  being  only  this  difference 
betwixt  them,  that,  in  the  one  case,  a  substance  is  separated 
from  the  blood,  which  formerly  existed  perfectly  in  it,  and 
which  exists  in  perfection  in  every  piece  of  matter,  whilst, 
'in  the  other,  the  living  power  produces  a  new  combination, 
and  different  arrangement,  of  the  principles  of  the  blood, 
forming  a  substance  which  neither  existed  in  it,  nor  else- 
where. Neither  the  one  nor  the  other  process  depends  upon 
any  active  changes  originating  in  the  blood  itself,  nor  upon 
chemical  principles  alone,  but  both  are  to  be  referred,  for 
their  production,  to  the  intricate  and  inexplicable  operation 
of  the  vital  energy.  The  production  of  animal  heat,  then, 
does  not  depend  directly  upon  the  diminution  of  the  capacity 
of  veinous  blood  for  combining  with  heat,  or  retaining  it, 
more  than  the  formation  of  bile  depends  upon  the  diminished 
ability  of  the  blood  in  the  liver,  to  retain  the  principles  of 
which  it  consists. 

The  feeling  of  heat,  then,  in  inflamed  parts,  will  be  great 
or  little,  according  to  the  capability  of  the  part  for  producing 
heat,  and  its  capability  of  receiving  the  sensation. 

From  these  remarks,  we  may  understand,  how  a  greater 
quantity  of  heat  is  produced  by  an  inflamed  part,  than  that 
part,  without  acute  inflammation,  would  produce.  *     We  may 


*  It  must  be  remembered,  however,  that  although  the  heat  of  a  part  be  aw 
increased  in  inflammation,  yet  we  are  not  to  judge  of  the  degree  by  the  sensaticu 
which  is  produced;  because,  owing  to  the  increased  sensibility  of  the  pari,  a  given 
stimulus  will  produce  a  greater  effect  than  formerly.  Hence,  the  contact  of  a 
foreign  body  gives  pain,  and  the  presence  of  little  more  than  the  usual  quantity  of 
heat  will  give  the  sensation  of  burning.    We  are  to  judge,  then,  of  the  rea  1  de- 


168 

also  understand,  how,  in  approaching  mortification,  the  heat 
is  little,  because  the  action  is  low,  although  it  yet  be  suffi- 
cient to  kill  the  weakened  part.  We  can  also  see,  why  the 
ioflammatio  assiiefacta,  or  what  has  been  called  passive  in- 
flammation, should  produce  much  less  heat,  than  the  inflam- 
matio  valida ;  because  the  action  rises  little  beyond  the  na- 
tural one,  in  degree,  when  compared  to  the  power  of  the 
part,  and  has  indeed  become  almost  habitual  to  it. 

The  inflammatory  action  natually  terminates  by  a  secre- 
tion, the  nature  of  which  varies  in  different  circumstances. 
Whenever  this  takes  place,  then  the  heat  of  the  part 
falls,  more  or  less,  from  its  morbid  degree  ;  because,  although 
the  action  be  still  unnatural  or  diseased,  yet  its  violence  is 
less. 

Even  the  presence  of  any  secretion,  although  not  depend- 
ent on  disease,  will  prevent  the  heat  from  being  raised  so 
high,  by  the  inflammatory  action,  as  it  otherwise  would  be  ;* 
one  cause  of  which  perhaps  is,  that  the  secretion  carries  off 
a  quantity  of  heat ;  another  is,  those  parts  which  secrete 
most  fluid,  have  least  capability  of  producing  heat. 

We  uniformly  find,  that  the  inflammatory  action  of  the 
parts  which  secrete  least,  is  attended  with  the  production  of 
most  heat.  The  skin  secretes  less  interstitial  fluid  than  other 
parts  ;  and,  although  it  sometimes  secretes  perspiration  co- 
piously, yet,  in  inflammation,  this  does  not  take  place.  It  is, 
therefore,  to  be  considered,  with  regard  to  inflammation,  as 
one  of  the  parts  which  secrete  least  ;  and,  on  this  account, 
the  heat  is  much  greater  in  inflammation  of  the  skin,  than  of 
other  parts  :  But. the. sensation  is  not  always  greater  ;  for,  in 


gree  of  hrnt,  not  by  the  sensation  of  the  patient,  but  by   the  feelings  which  it 
produces  in  another  pefsoft,  when  lie  touches  the  inflamed  part,  or  by  the  applica- 
tion of  the  thermometer. 
*  Hence,  inflammation  cf  the  urethra  is  attendee!  witfi  less  heat  tlian  inflanjnia- 
■  the  skin. 


169 

ententes,  the  sensation  is  very  acute,  owing  to  the  nature  of 
the  part  affected,  or  its  sensibility,  although  the  actual  in- 
crease is  perhaps  not  above  one  or  two  degrees  more  than  its 
natural  standard. 

All  increased  degrees  of  the  natural  action  give  the  sensa- 
tion of  heat,  whether  more  heat  be  really  present  or  not  ; 
because  the  effect  of  heat,  or  increased  action,  is  produced. 
The  sensation,  and  the  substance  which  we  call  heat,  are  two 
different  things,  the  one  being  an  effect,  the  other  a  cause  j 
or  the  one  an  action,  and  the  other  an  agent.  Now,  the 
same  effect  may  be  produced  by  various  causes  :  Thus,  the 
application  of  zinc  and  silver,  in  a  particular  manner,  to  the 
mouth,  will  produce  the  sensation  of  light,  as  certainly  as 
light  itself.  It  must,  however,  be  remembered,  that,  with 
respect  to  the  sensation  of  heat,  as  well  as  other  sensations^ 
different  parts  have  different  susceptibilities.  The  sensation 
of  touch  is  peculiarly  confined  to  the  cutis,  that  of  hearing 
to  the  ear,  &c.  In  the  same  way,  some  parts  have  a  greater 
susceptibility  for  receiving  the  sensation  called  heat,  than 
others.  This  sensation  is  strong  in  the  skin  and  bowels  ; 
but,  in  the  brain,  muscles,  bones,  &c.  heat  produces  a  some- 
what different  effect,  and  gives  a  sensation  of  a  different  na- 
ture. This  is  conformable  to  what  we  observe,  in  other  in 
stances,  of  the  effects  of  foreign  agents  ;  for  tin  re  is  no  fact 
better  ascertained  than  this,  that  agents  often  produce  differ- 
ent effects,  when  applied  to  different  individuals,  or  different 
parts  of  the  same  individual.  Hence,  in  simple  inflammation 
of  glands,  or  other  parts  lying  below  the  skin,  with  which  it 
does  not  exhibit  immediately  the  sympathy  of  association, 
we  find,  that  there  is  first  pain,  with  little  heat,  and  then 
more  heat,  in  proportion  as  the  inflammation  affects  the  cutis. 
As  long  as  there  is  pain,  without  much  heat,  we  may  con- 
clude, that  the  inflammation  is  not  making  a  rapid  progress 
toward  suppuration ;  for,  unless  in  some  specific  inflamma- 

vol.  i.  y 


5:70 

fcions,  the  surface  always  becomes  affected,  before  matter  i% 
formed  in  the  gland. 

Fiom  these  remarks,  which  are  supported  by  facts,  it  will 
appear,  ihat,  in  inflammation  of  the  surface,  the  heat  is  pro- 
duced in  greatest  quantity  by  the  cutis,  whilst  the  pain  pro- 
per to  inflammation  is  seated  chiefly  in  the  cellular  sub- 
stance. 

Actual  heat,  in  inflammation,  is  chiefly  produced  by  the 
cuticular  vessels  ;  and,  unless  these  be  affected,  the  degree 
of  heat  is  not  greaily  increased,  although,  in  very  delicate 
parts,  the  sensation  often  is.*  The  sensibility,  With  regard 
to  heat,  of  the  cellular  substance,  the  muscles,  the  parenchy- 
matous substance  of  the  lungs  and  the  liver,  the  substance  of 
tendons,  ligaments,  brain,  &c.  is  not  great ;  and,  therefore,  as 
the  inflammatory  action  in  them  is  not  attended  with  the 
production  of  much  actual  heat,  these,  when  inflamed,  give 
more  the  sensation  of  simple  pain,  than  of  heat.  On  the 
other  hand,  the  pleura,  which  is  more  sensible  than  those 
parts,  with  regard  to  heat,  when  inflamed,  gives  both 
the  sensation  of  sharp  pain,  and  also  of  moderate  heat. 
The  intestines,  again,  are,  in  this  respect,  highly  sensible, 
and,  when,  inflamed,  give  the  sensation  of  intolerable  heat, 
which  is  a  pathognomonic  symptom  of  ententes. 

It  is  impossible  to  account  for  the  variations  which  take 
place  in  the  production  of  heat,  by  the  inflammatory  action., 
upon  the  mechanical  principles  which  were  once  maintained, 
and  which  still  are  adopted  by  some.  It  was  the  opinion  of 
Boerhaav€,f  and  others,!  who  wrote  after  the  discovery  of 
the  circulation  of  the  blood,  that  the  heat  was  produced,  by 
the  attrition  of  the  red  globules,  against  the  sides  of  the  ves- 


*  It  has  been  ascertained  by  Mr.  Hunter,  that  the  actual  heat  of  the  muscles,, 
or  viscera,  is  very  little  increased  by  inflammation. 
i  Boerhaave,  Aph.  332 
^auvagp.  -N'oso'ofia  Method,  toin.i.  p.  383 


Hi 

sels  ;  and  the  same  is  embraced  by  a  modern  author,-'  as  one 
<-ause  of  i his  symptom.  But,  by  the  philosophy  which  ii 
now  taught,  it  appears,  that  a  fluid  may  flow  with  the  utmost 
velocity,  through  a  pipe,  for  a  thousand  years,  without  pro- 
duciag  a  single  degree  of  heat :  And  our  mechanics,  regard- 
less of  the  authority  of  either  Pitcaim  or  Bell,  seem  still  to 
believe,  that,  if  they  keep  their  machinery  moist,  there  is 
very  little  danger  of  its  being  inflamed  by  the  friction. 

Fever. — The  last  of  the  primary  symptoms  of  inflammar 
tion,  is  the  general  fever,  or  affection  of  the  system,  which 
often  attends  it.  This  is  sometimes  idiopathic  ;  that  is  to 
say,  it  sometimes  is  produced  at  the  same  time  with  the  local 
inflammation  ;  and  by  the  same  causes.  At  other  times,  it 
is  symptomatic  ;  that  is  to  say,  it  is  produced,  not  directly 
by  the  causes  which  originally  produced  the  inflammation, 
but  sympathetically  by  the  local  inflammation.  Both  of  these 
species  of  fever  are,  in  this  disease,  produced  exactly  in  the 
same  way,  although  by  different  exciting  causes  ;  and  the 
manner  of  their  production  may  be  understood,  from  the 
principles  which  are  laid  down  in  the  preliminary  disserta- 
tion. The  idiopathic  fever  is  always  preceded  by  coldness, 
because  the  action  is  always  formed  slowly.  This  coldness 
is  in  the  commencement  real,  and  afterwards  only  sensitive. 
There  is  at  first,  owing  to  the  diminution  of  the  natural  ac^ 
tion,  a  diminution  in  the  production  of  heat,  and,  consequent- 
ly, a  feeling  of  coldness.  This  sensation  continues  for  some 
time  after  the  actual  heat,  in  consequence  of  the  incipient, 
but  imperfect  action,  begins  to  be  increased,  which  has  been 
attributed  to  a  derangement  in  our  sensitive  faculty  :  But  it 
may  be  explained  in  a  different  manner ;  for,  as  increased  ac- 
tion is  productive  of  the  sensation  of  heat,  as  well  as  frequent- 
ly of  the  increase  of  actual  heat,  in  those  organs  which  are 

•  Bell's  Treatise  on  Ulcers,  p.  28. 


172 

peculiarly  fitted  to  secrete  it,  so  imperfect  or  diminished  ac- 
tion is  productive  of  the  sensation  of  cold.  During  the  first 
formation  of  an  action,  there  is  actual  coldness  produced ; 
but,  after  the  action  has  begun  to  take  place,  there  is  heat 
produced  in  a  certain  quantity  ;  but,  from  the  imperfection 
of  the  action,  cold  is  still  felt ;  because  the  same  state  which 
cold,  or  the  privation  of  heat,  produces,  is  present,  namely, 
an  imperfect  state  of  action.  The  sympathetic,  or  sympto- 
matic fever,  sometimes  appears  to  be  formed  without  any 
coldness  ;  because,  from  the  violence  of  the  exciting  cause, 
or  local  inflammation,  or  the  quickness  of  its  operation,  it  is 
excited  so  quickly,  that  we  do  not  attend  to  the  symptoms  of 
formation ;  but  these,  nevertheless,  do  take  place,  although, 
owing  to  this  cause,  their  continuance  be  short.  If,  however, 
the  local  inflammation  be  more  slowly  induced,  and,  conse- 
quently, operate  more  gradually  on  the  system,  then  the 
coldness  is  evidently  perceived.^  The  symptomatic  fever, 
induced  by  scalding  or  burning  a  part,  is  quickly  produced, 
and  we  have  very  little  time  to  attend  to  the  period  of  forma- 
tion. On  the  other  hand,  the  symptomatic  fever,  induced 
by  wounds,  is  excited  more  slowly,  and  the  period  of  forma- 
tion is  longer. 

This  fever  is  not  produced  by  inflammation,  if  it  affects 
parts  only  to  a  slight  degree  ;  but  it  uniformly  appears,  if  the 
local  inflammation  be  considerable,  or,  what  is  the  same  thing, 
affects  very  sensible  parts ;  and,  in  these  cases,  the  presence 
of  this  fever  is  a  criterion  of  the  presence  of  inflammation, 
in  parts  where  we  would  be  led  to  suspect  it,  but  cannot  say 
decidedly  from  other  symptoms.  Thus,  if  after  lithotomy, 
the  patient  complain  of  pain  in  the  abdomen,  we  will  be  led 


*  Coldness  is  felt  not  only  in  the  whole  body,  if  a  general  action  be  slowly  in- 
duced, but  it  is  also  felt  in  a  particular  part,  in  local  actions,  if  these  be  gradually 
induced.  Thus,  before  eruptions  appear  on  particular  parts  of  the  skin,  those  por- 
tions are  often  felt  cold. 


173 

to  conclude,  that  this  proceeds  from  inflammation  of  the  \  i- 
cera,  if  it  has  been  preceded  by  coldness,  and  accompanied 
with  heat ;  but  if  no  shivering  has  taken  place,  and  the  pulse 
be  not  much  affected,   it  proceeds  most  probably  from  a  dif- 
ferent cause. 

The  degree  to  which  this  fever  will  be  excited,  depend* 
not  upon  the  absolute  quantity  or  violence  of  the  inflammato- 
ry action,  but  in  a  great  measure,  upon  the  degree  of  the  lo- 
cal inflammatory  action,  compared  to  the  natural  power  and 
action  of  the  part.  Those  parts  whose  action  is  naturally 
low,  and,  consequently,  whose  energy  is  also  small,  are  ex- 
tremely painful,  when  inflamed,  and  the  system  sympathises 
greatly  with  them,  although  the  real  quantity  of  inflammatory 
action,  considered  absolutely,  be  trifling.  Hence,  inflamma- 
tion of  tendons,  bones,  or  ligaments,  affect  the  constitution 
greatly ;  and,  from  the  same  cause,  it  will  appear,  that  agents 
which  induce  violent  inflammation  in  joints,  (by  which  I  mean 
absolutely  great  inflammatory  action,)  will  rapidly  produce 
sloughs  of  the  part,  and  death  to  the  patient,  in  no  very  long 
time,  if  it  be  not  subdued.  If,  on  the  other  hand,  the  agents 
have  acted  less  powerfully,  then  sloughs  are  not  produced, 
but  the  system  is  as  much  affected  as  it  would  be  by  a  much 
greater  degree  of  local  inflammatory  action  in  some  other 
parts.  Those  parts,  again,  which  are  very  sensible,  affect 
the  constitution  greatly,  in  the  same  way,  and  on  the  same 
principle  nearly,  as  those  whose  action  is  naturally  low ;  be- 
cause slight  causes  induce  the  same  disproportionate  action 
in  them;  and  hence  they  are  soon  destroyed.  In  this  way, 
inflammation  of  the  bowels  affects  the  system  greatly,  and  lo- 
cal mortification  is  also  rapidly  produced. 

There  is,  however,  another  cause  co-operating  with  this 
one,  in  the  present  instance,  to  produce  a  general  sympathy, 
namely,  the  natural  sympathy  which  exists  betwixt  the  sto- 
mach and  intestines,  and  the  rest  of  the  body,  by  which  inju- 


m 

ries  clone  to  them  affect  the  system  very  rapidly ;  a  slight 
disorder  of  the  stomach,  for  instance,  sometimes  producing 
syncope.  This  does  not  depend,  as  Mr.  Hunter*  supposes, 
upon  the  stomach  being  the  receptacle  of,  what  he  calls,  sim- 
ple life ;  because  the  existence  or  such  a  receptacle  is  con- 
trary to  the  general  nature  of  the  animal  economy ;  and  I 
know  of  no  proofs  which  establish  its  existence. 

Of  the  Consequences  of  Inflammation. 

Having  made  these  remarks  upon  the  production  of  the 
symptoms  of  inflammation,  I  shall  now  proceed  to  consider 
its  most  frequent  consequences  or  terminations,  which  have 
generally  been  said  to  be,  adhesion  or  resolution,  suppuration, 
and  mortification. 

Adhesion. — To  illustrate  the  important  process  of  adhe- 
sion, or  the  union  of  two  living  parts,  which  have  once  been 
divided,  it  may  not  be  improper  to  attend  to  the  cause  of  re- 
production in  general,  or  the  replacement  of  those  particles 
which  are  daily  absorbed.  Neither  absorption  nor  reproduc- 
tion can  take  place  in  a  dead  body,  but  depend  entirely  on 
the  action  of  the  living  principle.  If  this  action  be  impaired, 
these  functions  are  imperfectly  performed.  If,  on  the  other 
hand,  it  be  too  high,  then  those  processes  are  too  rapidly  car 


**' AH  the  parts  that  may,  in  one  sense,  be  called  vital,  do  not  produce  the  same 
"  effect  mpon  the  constitution;  and  the  difference  seems  to  arise  from  the  differ  - 
"  ence  in  their  connections  with  the  stomach.  It  is  to  be  observed,  that  vital  parts 
w  may  be  divided  iuto  two;  one ,  which  is  in  itself  immediately  connected  with 
"  life,  as  the  stomach;  the  other,  where  life  only  depends  upon  it  in  its  action  or 
*'  use:  The  heart,  lung-',  and  brain  are  only  to  be  considered  in  this  last  light."— 
"  If  the  stomach  is  inflamed,  the  patient  feels  an  oppression  and  dejection  through 
**  all  the  stages  of  the  inflammation.  Simple  animal  life  seems  to  be  hurt  or  lessen 
"  ed,  just  as  sensation  is  lessened  when  the  brain  is  injured." 

Hunter  on  Inflammation,  p.  324,  323. 

"  The  stomach  is  the  seat  of  simple  animal  life,  and  thereby  the  organ  of  univer- 
'-'  sal  sympathy  of  the  materia  vitae."  P.  402. 


175 

ried  on,  and  the  new  matter  which  is  deposited,  is  incom- 
pletely organized ;  its  life  is  likewise  less  perfect,  and  its  con- 
tinuance is  short.  This  is  illustrated,  by  what  we  observe 
in  ulcers  and  inflamed  parts.  The  new  matter,  or  the  organic 
particles,  are  furnished  entirely  by  the  arteries,  and  deposit- 
ed by  them,  under  the  direction  of  the  nerves ;  and  the  na- 
ture and  organization  of  this  matter  varies  with  the  action.* 
These  particles  are  furnished,  at  the  moment  of  their  forma- 
tion, with  the  specific  life  of  the  animal,  in  a  degree  propor- 
tioned to  the  perfection  of  the  formation ;  and  their  natural 
longevity  observes  the  same  ratio.  They  live  and  die  from 
the  same  causes  which  influence  the  life  of  the  body,  consi- 
dered as  a  whole  ;  but  their  duration  is  infinitely  shorter  than 
that  of  the  body.  They  quickly  perish,  or  descend  in  the. 
scale  of  existence;  they  are  alternately  absorbed  and  replac- 
ed. There  is,  thus,  a  continual  round  of  death f  and  repro- 
duction going  forward  in  the  animal  frame. 

In  order  that  this  process  may  go  on,  or  that  reproduction 
may  take  place,  it  is  necessary,  that  a  void  be  formed,  by  the 
absorption  of  the  old  matter ;  which  void  is  filled  up  by  new 
particles,  which  adhere  together,  and  preserve  the  organiza 
tion  of  the  part.  If  this  void,  instead  of  being  made  slowh 
by  absorption,  and  being  filled  up  the  moment  that  it  is  form 
ed,  be  made  suddenly,  and  of  a  considerable  size,  by  incision. 
the  same  effect  is,  in  the  end,  produced.  The  arteries  which 
we  cut,  pour  out  their  blood,  but  the   quantity  is  gradually 


*  The  action,  at  the  surface,  forms  skin,  and  that  in  the  muscle,  forms  : 
As  long  as  the  actions  of  the  part  remain  the  same,  then  a  similar  matter 
nished ;  but  when  the  action  changes,  then  the  matter  also  change?.    Thus,  for  in 
stance,  bone  is  sometimes  formed  in  the  place  of  membrane,  Lc. 

t  Death  is  the  descending  of  any  substance  from  a  higher  to  a  lower  species  oi 
existence,  or  from  a  more  perfect  to  a  less  perfect  vitality;  for  there  can  be  i>c- 
such  thing  as  absolute  death,  that  is  to  say,  complete  deprivation  of  a  vital  prir. 
ciple,  until  the  same  Great  Power  who  original1;.'  gave  existence  A.^ -^:r 
pleased,  by  his  sovereign  will,  to  annihilate  it 


176 

diminished,  until  it  ceases  altogether,  and  a  different  and 
more  limpid  matter  drops  out.  This  has  been  called,  by 
some,  the  lymph,  and  by  others,  the  serum,  which  filtered 
through  the  contracting  vessels.  But,  were  this  mechanical 
notion  true,  then,  by  varying  the  degree  of  pressure,  and 
thus  changing  the  diameter  of  the  vessels,  we  should,  at  plea- 
sure, make  the  discharge  either  red  or  limpid.  It  is  more 
probable,  that  this  is  one  of  the  most  simple  secretions  which 
the  blood  yields,  and  that  the  appearance  is  regulated  by  the 
action  of  the  vessels.  If  the  edges  of  the  wound  be  laid 
closely  together,  we  next  find,  that  the  divided  vessels,  which 
have  now  become  extremities,  receive  the  action  which  the 
extremities  formerly  used  to  have,  when  a  void  was  formed 
by  absorption. *  They  throw  out  matter  nearly  the  same 
with  that  which  was  formerly  yielded,  and  the  structure  of 
the  part  is  restored.  I  have  said  nearly ;  because,  from  the 
attending  circumstances,  the  action  cannot  be  so  perfect  as 
formerly ;  and,  therefore,  the  matter  furnished  will  not  be  at 
first  exactly  the  same,  and  the  deviation  will  be  proportioned 
to  the  degree  in  which  the  action,  in  consequence  of  the  in- 
jury, is  increased  beyond  what  it  was  in  health.  Hence,  in 
parts  where  the  action  was  slow  in  its  performance,  and  small 
in  quantity,  the  deviation  will  be  most.  Thus,  when  a  bone 
is  fractured,  the  callus  is  much  softer  than  old  bone ;  it  is 
formed  in  greater  quantity  than  formerly,  and  it  requires 
aome  time  before  it  is  formed  in  the  necessary  degree  of  per- 
fection, to  enable  the  person  to  make  use  of  the  bone.  But 
a  similar  injury  done  to  the  skin,  or  a  muscle,  will  not  be  at- 
tended with  the  same  effects  ;  for  the  action  is  there,  in  health, 
much  quicker  and  much  greater :  The  deviation  is,  therefore, 
from  the  first,  trifling,  and  soon  ceases. 


*  If,  however,  the  void  he  larger  than  it  -night  to  be,  owing  to  the  sides  of  the 
wound  not  being  laid  closely  together,  then  this  process  does  not  take  place,  but 
the  part  inflames,  as  has  been  formerly  explained. 


m 

Some  have  considered  the  process  of  adhesion  in  a  more 
mechanical  light,  and  have  supposed,  that  the  lymph  was 
poured  out,  and  glued  the  parts  together,  and  afforded  a  bed, 
into  which  the  vessels  from  the  opposite  surfaces  might  ra- 
mify, by  which  union  was  produced.  This  takes  place,  in 
the  opinion  of  Mr.  Hunter,  owing  to  the  vitality  of  the  blood ; 
but  I  apprehend,  that  it  is  fully  proved,  that  whenever  blood 
is  extravasated,  it  loses  its  animal  life,  and  proves  a  stimulus 
to  the  wound,  preventing  it  from  uniting,  unless  the  quantity 
be  very  small,  in  which  case  it  is  absorbed,  and  is  thus  re- 
moved. It  is  our  great  care,  in  surgical  operations,  to  tie  the 
vessels,  and  clear  the  surface  from  blood,  in  order  to  procure 
union,  which  ought  to  be  attended  with  an  effect  contrary  to 
our  wishes,  were  adhesion  to  depend  upon  the  uniting  medium 
of  the  blood.  Mr.  Hunter  likewise  supposes,  that  coagula 
have  the  powrer  of  becoming  vascular  of  themselves,  and  thus 
more  firmly  uniting  the  parts ;  but  this  is  assuredly  ascribing 
the  actions  of  one  species  of  life,  and  of  one  body,  to  that  of 
another  :  We  might  as  well  attribute  the  actions  of  the  life 
of  a  quadruped  to  the  living  principle  of  the  polypus. 

The  perceptible  operations  of  the  life  of  the  blood  are  very 
£ew,  and  quite  distinct  from  those  of  an  organized  animal.  If 
it  ever  were  to  perform  other  actions,  and  assume  an  orga? 
nized  form,  then  it  must  cease  to  be  blood,  and  become  a  sub- 
stance with  which  we  have  no  acquaintance ;  for,  hitherto, 
we  know  of  no  substance  which  can  become  a  part  of  an  ani- 
mal, and  receive  a  regular  form,  except  through  the  interven- 
tion of  the  nerves  and  vessels,  which  by  regular  gradations, 
change  foreign  matters  into  part  of  the  animal.  It  has,  in- 
deed, been  said,  that  clots  of  blood  have  been  injected  ;  but, 
by  the  same  experiment,  we  might  also  prove,  that  a  sponge, 
or  a  bit  of  woollen  cloth,  were  also  vascular. 

Adhesion  appears  to  be  a  more  delicate  process,  than  join- 
ing parts  with  mucus,  lymph,  or  any  intermediate  substance 

vol.  i.  z 


178 

whatever.  It  appears  to  be  nothing  less  than  the  action  of 
that  power,  which  is  always  operating  in  the  system,  and 
restoring  the  waste  of  the  body  ;  but,  from  the  circumstances 
under  which  it  is  exercised,  and  the  causes  which  tend  to 
make  it  imperfect,  the  substance  which  is  thrown  out  is  not 
always  perfectly  similar  to  the  adjoining  parts,  at  least  in  ex- 
tensive wounds. 

This  process,  which,  when  carried  on  in  health,  is  called 
nutrition,  has,  in  disease,  been  named  the  adhesive  inflamma- 
tion. But  the  term  is  improper;  for  adhesion  never  takes 
place,  until  inflammation  subsides  ;  and  it  often  is  produced 
without  auy  previous  inflammation,  and  quke  independent  of 
it,  without  heat,  without  pain,  and  without  extensive  redness. 
Whenever  a  wound  inflames,  its  lips  separate,  and  pain  is 
produced:  When  the  inflammation  is  removed,,  then  the  parts 
adhere,  and  the  pain  .eases.  Adhesion  is,  in  this  case,  sy- 
nonymous  with  resolution  ;  indeed,  resolution  is  almost  al- 
ways attended  with  adhesion.  There  is,  however,  this  differ- 
ence betwixt  them,  that  adhesion  may  take  place  without 
previous  inflammation,  whereas  resolution  implies  the  exis- 
tence of  that  disease.  If,  however,  inflammation  has  preced- 
ed adhesion,  then  it  is  exactly  the  same  wilh  resolution,  be- 
ing a  termination  of  the  inflammatory  action.  He,  then,  who 
would  talk  of  the  adhesive  inflammation,  is  just  as  much  mis- 
taken, as  he  who  would  speak  of  the  resolving  inflammation. 

In  the  natural  state  of  the  body,  we  find  skin  adhering  to 
cellular  substance,  and  this  to  muscle,  and  this  again  to  bone  ; 
and  the  same  union  takes  place  in  disease,  two  dissimilar  sub- 
stances often  joining  together,  or  adhering  ;  but,  for  this  pur- 
pose, it  is  necessary  that  both  be  alive,  and  that  the  actions 
of  both  be  in  a  proportioned  degree. 

These  observations  on  adhesion,  will  serve  to  explain  the 
termination  of  inflammation,  called  resolution;  and,  therefore, 
little  more  will  be  required  to  be  said  on  that  subject.     Reso- 


J  79 

iution  is,  by  some,  said  to  be  merely  a  cessation  of  inflamma- 
tion, the  parts  returning  gradually  to  their  former  state,  with- 
out any  intermediate  condition.  But,  if  we  attend  more  mi- 
nutely to  the  subject,  we  shall  find,  that  the  inflammatory  ac- 
tion, like  every  o'.her  new  action,  uniformly  terminates  by  a 
secretion.  Some  actions  terminate  in  new  secretions,  whilst 
others  only  increase  the  quantity  of  old  ones.  When  the  in- 
flammatory action  subsides,  we  have  an  increased  discharge 
of  the  proper  secretion  of  the  part,  or  inteisti  ial  fluid,  which 
is  also  considerably  changed  in  its  nature,  and  becomes  thin- 
ner than  it  was  during  the  continuance  of  the  inflammatory 
action.*  The  part,  therefore,  remains  swelled,  until  this  flu- 
id be  absorbed ;  but  the  swelling  is  more  diffused  and  cedoma- 
tous,  and  the  pain  is  gone,  together  with  the  redness.  The 
organic  particles  are  likewise  deposited  in  greater  perfection, 
and  may  be  said  to  be  a  secretory  termination  of  inflamma- 
tion; because,  during  the  violence  of  the  inflammatory  action, 
they  were  furnished  in  a  very  imperfect  state,  and  were  dif- 
ferent from  what  they  ought  to  be  :  But,  when  resolution  is 
accomplished,  they  become  again  natural,  and  produce  either 
adhesion,  if  there  has  been  a  division,  or  a  renewal  of  the 
proper  structure  which  has  been  destroyed  by  the  inflamma 
tion,  rendering  the  formative  or  nutritive  action  imperfect. 

Suppuration. — If  resolution  do  not  take  place,  owing  to 
the  original  violence  of  the  inflammatory  action,  or  from  any 
other  cause,  then,  if  the  part  be  not  killed,  a  secretion  of  a 
different  kind  takes  place,  and  the  inflammation  is  said  toter 
minate  by  suppuration. 

Concerning  the  formation,  nature,  and  uses  of  pus,  many 
opinions  have  prevailed  ;  but,  by  much  the  most  universal,  is 
founded  on  the   ancient  doctrines  of  fermentation.     Bv  the 


*  It  is  owing  to  this,  that,  duriag  resolution,  the  part  becomes  softer,  although 
Uie  swelling  be  much  the  same  as  formerly. 


180 

Grecian  physicians,  pus  was  considered  as  a  concoction  of 
the  blood  or  humours,  effected  by  the  powers  of  life,  or  by 
nature  ;  and,  therefore,  the  state  of  ulcers  was  attended  to 
very  much  by  Hippocrates,  in  forming  his  prognosis,  as  he 
thus  ascertained  the  degree  of  vital  power,  and  the  extent  of 
the  operations  of  nature.  When  the  blood  was  effused  into 
the  cellular  substance,  then  it  was  supposed  to  undergo  a  spe- 
cies of  putrefaction  or  concoction,  and  to  become  converted 
into  pus.* 

When  the  component  parts  of  the  blood  came  to  be  well 
understood,  and  when  the  humoural  pathology  came  to  be  il- 
lustrated by  experiments,  attempts  were  made  to  discover 
which  part  of  the  blood  yielded  the  purulent  matter.  From 
some  observations  on  the  serum  of  the  blood,  Sir  John  Prin- 
gle  was  led  to  believe,  that  pus  was  formed  by  a  concoction 
of  the  serum ;  for,  by  exposing  this  fluid,  for  some  time,  to  a 
heat  equal  to  that  of  the  human  body,  a  deposition  was  form- 
ed, bearing  some  distant  resemblance  to  pus,  from  which  it 
was  considered  as  allowable  to  conclude,  that  inflammation 
produced  an  effusion  of  serum,  and  that  this  serum  was  by 
heat  converted  into  pus.  This  opinion  was  keenly  maintain- 
ed by  Mr.  Gaber,  who  adduced  many  experiments  similar  to 
that  just  mentioned,  in  order  to  prove  the  doctrine.  Upon 
these  authorities,  the  doctrine  of  fermentation  was  adopted 
by  Dr.  Cullen,  and  copied  from  him  by  Mr.  Bell,  neither  of 
whom  seem  to  have  remembered,  that  the  productions  which 
are  yielded  by  an  animal,  either  in  health  or  disease,  are 
yielded  by  processes  peculiar  to  animal  life,  and  which  they 
cannot  possibly  imitate  by  any  skill,  or  by  the  most  elaborate 
concoction.  That  heat  will  coagulate  a  small  portion  of  the 
serum,  and  make  it  furnish  a  precipitate,  is  a  well-known 


*  "  Suppurantur  autcm  alterato  sanguine  ac  calefacto,  donee  putrefactus  taliuic 
ulcerium  pus  Gat."  Hippoc,  it  Ulceribib. 


181 

fact ;  but  it  does  not  thence  follow,  that  it  deposits  pus.  If 
the  mere  circumstances  of  becoming  white  and  thick,  were 
considered  as  the  only  necessary  changes  which  a  fluid  must 
undergo,  in  order  to  be  converted  into  pus,  then  the  lymph 
would  be  a  much  better  subject  for  experiment-makers  to 
work  upon,  than  the  serum.  Even  the  urine  itself  might  be 
proved  to  be  the  source  of  pus ;  because  Sir  John  Pringle,* 
the  great  authority  upon  this  subject,  allows,  that  this  excre- 
tion, in  health,  yields  a  precipitate  entirely  the  same  with 
that  which  is  furnished  by  the  serum,  and  which,  he  suppo- 
ses, is  a  redundant  portion  of  the  nutritious  matter  escaping 
by  the  kidneys.  But  a  positive  proof  against  this  opinion  of 
concoction,  is  obtained,  by  considering  the  situations  in  which 
pus  is  formed ;  for  we  find  it  covering  ulcers  speedily  after 
they  have  been  wiped  clean.  Now,  had  pus  been  formed 
from  serum,  this  serum  could  never  have  had  time  to  have 
been  digested,  and  it  would  have  been  absorbed  by  the  dress* 
ings  which  were  applied.  Again,  when  the  lungs  become 
inflamed,  in  people  who  have  water  in  the  chest,  or  when  en- 
tentes is  conjoined  with  dropsy,  we  find  fhe  inflamed  viscera 
covered  with  pus  ;  but,  unless  inflammation  has  been  present, 
we  never  find  pus  in  hydrothorax  or  ascites  alone.  It  must, 
then,  in  the  cases  where  we  find  it,  be  considered  as  a  secre- 
tion produced  by  inflammation,  and  not  the  result  of  concoc- 
tion, otherwise  we  should  find  it  in  every  case  of  dropsy. 

Some  have  supposed,  that  pus  was  produced  by  the  disso- 
lution of  the  inflamed  part ;  but  the  putrefactive  fermenta- 
tion yields  a  very  different  product  from  pus  :  Besides,  in 
ulcers,  we  daily  observe  an  abundant  flow  of  matter,  without 
the  smallest  loss  of  substance. 

It  has  been  already  mentioned,  that  the  inflammatory  ac- 
tion changes  very  much  the  nature  both  of  the  interstitial 

*  Observations,  &c.  p.  33D. 


182 

fluid  and  Organic  particles;  and  these  changes  may  be  con 
sidered  as  approximations  toward  the  production  of  pus,  it' 
we  consider  this  as  the  ultimate  secretion  which  is  to  be 
formed.  From  the  continuance  and  degree  of  the  inflamma- 
tory action,  the  interstitial  fluid  becomes  still  more  different 
from  what  it  ought  to  be,  and  the  organic  particles  become 
so  imperfect,  that  they  cannot  supply  the  waste  of  the  part, 
•?r  renew  its  structure  :  The  form  of  the  part  is  then  destroy- 
ed, and  the  cavity  filled  with  a  double  secretion,*  called  pus.f 
These  observations  apply  to  parts  of  a  simple  nature  ;  that  is 
to  say,  parts  which  only  form  matter,  to  renew  their  loss  by 
absorption,  and  interstitial  fluid.  But  there  are  other  parts, 
which  have  a  third  set  of  vessels,  which  are  intended  to  se- 
crete a  matter  not  immediately  subservient  to  the  support  of 
the  part.  When  these  parts  are  inflamed  to  such  a  degree, 
as  to  induce  the  purulent  secretion,  then  this  fluid  will  also  be 
changed,  and  form  a  third  component  part  of  pus,  as  we  ob- 
serve, for  instance,  in  the  mamma?,  during  lactation,!  if  the 
true  glandular  part  has  suppurated.  If,  however,  the  in- 
flammation has  been  less  violent,  then  the  inflamed  gland  still 
continues  to  yield  a  milky  secretion  ;  but  the  milk  yielded  by 
that  gland  is  not  the  same  with  that  furnished  by  the  rest. 
At  other  times,  those  third  set  of  vessels  yield  the  greatest 


*  Namely,  the  new  or  imperfect  substance  yielded  by  the  vessels,  which  former- 
ly deposited  organic  particles,  but  especially  the  changed  interstitial  fluid  :  These 
nniting,  form  otte  substance,  which  is  called  pus. 

f  Pus  has  been  considered  as  a  peculiar  fluid,  of  a  simple  and  homogenous  na- 
ture; but,  from  this  doctrine,  which  I  apprehend  to  be  true,  it  will  appear  to  be  a 
roQipoand  body,  consisting  often  of  more  secretions  than  one,  and  differing  in  dif- 
ferent organs.  The  appellation  of  pus,  however,  is  generally  confined  to  a  yellow - 
i.a  bland  fluid,  of  the  consistence  of  cream,  which,  like  other  animal  secretions, 
contains  a  quantity  of  globules. 

J  If  the  breasts  be  not  in  a  secreting  !state  when  inflamed,  then  they  are  to  be 
♦oosidered  just  as  the  simple  parts  above  mentioned.  They  are  likewise,  even 
daring  lactation,  to  be  considered  as  simple  parts,  if  the  cellular  substance  alone 
1»e  inflamed,  as  is  frequently  the  case;  for  ike  glandular  portion  does  not  always 
suffer  in  these  cases. 


183 

part  of  the  secretion  in  inflammation,  as  we  see  in  the  ure- 
thra ;  but,  in  this  case,  the  inflammatory  action  is  moderate, 
and  the  organic  particles  and  interstitial  fluid  are  not  much 
affected ;  the  first  of  these,  at  least,  forming  no  part  of  the 
discharge,  being  perfect  enough  to  remain  as  constituent  parts 
of  the  organ. 

This  process  takes  place,  in  different  species  of  inflamma- 
tion, with  different  degrees  of  rapidity  ;  and  the  proportion 
of  the  different  substances  which  form  pus  also  varies.  In 
simple  inflammation,  the  quickness  of  the  process  depends, 
in  part,  upon  the  nature  of  the  organ  affected,  but  chiefly 
upon  the  violence  of  the  action.  The  component  parts, 
again,  depend  chiefly  upon  the  nature  of  the  part  affected, 
but  also,  in  part,  on  the  degree  of  action.  When  bones  in- 
flame and  suppurate,  which  they  do  slowly,  it  is  chiefly  the 
interstitial  fluid,  in  a  changed  state,  which  is  furnished,  the 
discharge  being  thin,  and  often  greasy.*  Tendons  yield 
both  the  interstitial  fluid,  and  part  of  the  organic  particle.-. 
but  chiefly  the  fluid  which  lubricates  their  surface.  Muscles, 
the  brain,  parenchymatous  substance  of  the  lungs,  liver,  Sec 
and  cellular  substance,  yield  both  interstitial  fluid,  and  or- 
ganic particles,  in  the  same  proportion,  in  equal  degrees  of 
inflammation  ;  and  the  discharge  is  little  different,  to  appear- 
ance, in  these  different  parts.  Lymphatic  glandsf  yield 
chiefly  the  interstitial  fluid,  but  also  partly  the  organic  mat 
ter,  and  most  likely  part  of  the  lymph  which  they  transmit  - 
The  conglomerate  glands  yield  both  the  interstitial  fluid  and 
organic  particles ;  but  the  latter,  unless  in  violent  inflamma- 
tion, are  in  small  quantity  :  They  also  yield  their  own  pecu 


*  We  must  distinguish  betwixt  the  fluid  which  comes  from  the  bone,  and  thai 
which  is  furnished  by  the  ulcer  of  the  soft  parts  which  cover  i' 

f  Lymphatic  glands  are,  in  one  view,  to  be  considered  as  secretory  organs;  for 
they  undoubtedly  give  out  the  lymph  in  a  different  state  from  that  in  '5!»^l^'', 
tared  them:  otherwise  we  can  percei**  no  rise  for  them 


184 

liar  secretion,  in  an  altered  state.  The  testicles,  for  instance, 
when  they  suppurate,  give  a  discharge,  which  consists  of 
these  three  substances,  but  chiefly  of  the  first,  next  of  the 
last,  and  in  least  quantity  the  organic  matter.  Along  with 
this  is  discharged  the  old  substance  of  the  testicles,  (which 
has  not  been  yet  absorbed,)  like  threads.  Mucous  mem- 
branes, when  they  suppurate,  yield  chiefly  their  usual  dis- 
charge, in  an  altered  state,  next  the  interstitial  fluid,  in  a 
smaller  quantity,  with  scarcely  any  organic  matter,  the  in- 
flammation being  seldom  so  high  as  to  destroy  its  organiza- 
tion. 

The  chills  which  precede  extensive  suppuration,  or  suppu- 
ration in  delicate  parts,  are  to  be  accounted  for  upon  the 
general  principle  already  mentioned,  of  every  new  action  be- 
ing preceded  by  symptoms  of  weakness  during  its  formation. 
Mr.  Hunter  supposes,  that  the  stomach  is  the  great  cause  of 
those  rigours,  in  consequence  of  its  being  "  the  seat  of  simple 
animal  life,  and  thereby  the  organ  of  universal  sympathy  of 
the  materia  vitae."  It  is,  therefore,  affected  in  all  diseases  ; 
and  the  same  effect  is  produced,  as  if  directly  injurious 
causes  were  applied  to  itself;  which  "  disagreeable  applica- 
tions" produced  coldness  :  But  it  surely  does  not  follow,  that, 
because  whatever  excites  squeamishness,  induces  a  tempora- 
ry feeing  of  cold,  therefore  cold  is  always  induced,  in  disease, 
by  a  similar  state  being  excited. 

The  coldness  which  precedes  suppuration,  is  great  or  little, 
according  to  the  same  causes  which  influence  the  degree  of 
the  cold  fit  which  precedes  inflammation,  namely,  the  extent 
and  degree  of  the  action,  and  the  delicacy  of  the  part  affect- 
ed. The  effect  upon  the  system,  of  the  purulent  action, 
after  it  is  fully  formed,  is  likewise  proportioned  to  these  cir- 
cumstances. Every  local  action,  if  extensive  or  violent,  or 
if  it  exist  in  delicate  parts,  must  affect  the  constitution,  and 
induce  a  general  disease.     This  is  uniformly    an  affection 


185 

somewhat  similar  to  the  local  action,  although  the  symptoms 
be  in  a  much  less  degree,  and  sometimes  different.  Thus, 
the  local  inflammatory  action  produces  pain,  heat,  redness, 
and  swelling  ;  but  the  general  action  produces  only  heat, 
slight  redness,  and  uneasiness,  partaking  rather  of  the  nature 
of  anxiety  than  pain.  In  the  same  way,  the  purulent  action, 
which  is  a  depraved  action  of  the  formative  vessels  of  a  part, 
produces,  when  it  affects  the  system,  an  universal  affection 
or  derangement  of  these  vessels,  or  a  diseased  action  in  them, 
marked  by  frequency  of  pulse,  and  emaciation  ;  the  function 
of  nutrition,  or  the  deposition  of  organic  particles,  not  being 
properly  performed.*  It  is  to  this  cause,  I  apprehend,  and 
not  to  the  mere  formation  of  a  quantity  of  fluid,  called  pus, 
that  we  are  to  attribute  the  bad  effects  of  extensive  suppu- 
ration, or  ulcerations,  or  suppurations  of  the  vital  parts  ;  for 
we  cannot  suppose,  that  weakness,  or  hectic  fever,  is  induced 
by  these  abscesses  or  ulcers  acting  merely  as  drains,  destroy- 
ing a  certain  quantity  of  blood,  or  nutritious  fluid  ;  otherwise 
the  effect  must  always  be  proportioned  to  the  quantity  of 
matter,  which  is  not  uniformly  the  case. 

When  matter  is  formed  in  a  part,  it  is  sometimes  removed 
by  absorption  :  The  sides  of  the  abscess  are  thus  allowed 
to  come  together,  whilst  the  purulent  action  abates,  and  the 
nutritive  one  returns,  in  consequence  of  which  the  part  is 
again  restored  to  its  proper  condition.  But,  more  frequent- 
ly, the  purulent  action  extends  toward  the  surface  ;  (for  alt 
actions  tend  thither  ;)  which,  consequently,  has  its  organiza- 
tion destroyed,  the  vessels  of  the  cellular  membranes  and 
cutis  forming  pus  ;  so  that,  at  last,  at  some  particular  part 
where  the  purulent  action  has  advanced  most,  the  matter 


*  Hectic  fever  is  never  produced,  except  by  such  causes  as  affect  the  action  of 
nutrition ;  such  as  the  purulent  action,  swelling  of  the  mesenteric  gland?,  dia 
betes,  &c. 

VOL.    I.  2   A 


186 

comes  to  be  covered  only  with  the  cuticle,  which  soon  bursts, 
and  allows  the  pus  to  escape  :  The  absr  ess  is  then  healed, 
in  the  same  way  as  in  the  former  instance,  and  bo  h  in  the 
same  way  nearly  as  ulcers,  which  will  be  immediately  illus- 
trated ;  and,  therefore,  I  shall  not  explain  here  the  mode  by 
which  abscesses  are  healed. 

It  is  in  consequence  of  the  tendency  of  all  actions  to  af- 
fect the  surface,  and  approach  to  it,  that  abscesses  spread 
outward,  instead  of  extending  laterally,  or  inward.*  The 
matter  has  been  supposed  to  be  prevented  from  spreading 
through  the  neighbouring  parts,  by  a  coat  of  coagulated 
lymph,  which  lined  the  abscess ;  but  it  rather  appears,  that 
the  whole  of  the  inflamed  part  does  not  suppurate,  but  that 
suppuration  begins  first  either  about  the  centre,  or  rather 
somewhere  between  the  centre  and  the  external  surface, 
leaving  a  hard  portion  below,  and  on  every  side  of  it  :  This 
gradually  grows  less  ;  but  still  the  purulent  action  has  reach- 
ed the  surface,  before  it  has  affected  the  lateral  margin  ;  and, 
therefore,  there  is  always  a  hardened  portion  surrounding  the 
abscess,  until  it  bursts,  and  for  some  time  afterwards  :  But 
this  hardened  circle,  or  stool,  as  it  has  been  called,  is  not 
formed  by  an  effusion  of  lymph,  induced  for  the  purpose  of 
confining  the  matter,  but  is  the  consequence  of  the  whole  of 
the  inflamed  part  not  having  yet  assumed  the  purulent  ac- 
tion. 

When  a  considerable  portion  of  the  surface  has  assumed 
the  purulent  action,  then  the  abscess  becomes  exposed,  and 
an  ulcer  is  said  to  be  formed,  which  is  healed  by  the  same 
process  which  heals  an  abscess,  when  it  discharges  its  matter 


*  Mr.  Hunter  attributes  this  to  absorption,  produced  by  pressure,  which  acti 
more  upon  the  external  surface,  than  the  sides  or  bottom,  owing  to  "  a  redness  in 
the  parts  to  be  freed  from  a  disease  already  existing-"  The  cellular  substance 
is  likewise  fuppos^d  to  be  "  more  susceptible  of  this  irritation"  than  other  parts, 
and,  consequently,  is  more  quickly  absorbed. 


187 

by  a  small  opening,  or  when  the  matter  is  absorbed  ;  namely, 
the  natural  action  slowly  returns,  the  purulent  one  disappear- 
ing, and  the  proper  organic  particles  being  again  replaced. 

The  vessels  which  deposit  organic  particles,  seem  to  re- 
ceive their  natural  action  first,  throwing  out  what  are  called 
granulations,  whilst  the  vessels  which  secrete  interstitial  fluid, 
are  longer  of  receiving  their  proper  action,  and  still  yield  a 
purulent  discharge  ;  but  this  is  not,  as  must  be  evident,  ex- 
actly the  same  with  the  pus  of  abscesses. 

Even  the  whole  of  the  vessels  which  furnish  organic  par- 
ticles, do  not  receive  the  action  at  the  same  time  ;  but  one 
vessel  after  another  seems  to  lose  the  purulent  action,  and  de- 
posit proper  granulations,  which,  from  the  vascularity  of  the 
part,  are  soft,  and  of  a  red  colour.  These,  from  the  imper- 
fection of  the  action  which  forms  them,  in  the  beginning  of 
the  healing  process,  die  soon,  and  are  quickly  absorbed ;  but 
they  are  as  speedily  reproduced,  and  every  day  renders 
them  more  perfect,  and  brings  them  nearer  to  their  natural 
longevity.  The  formative  action  seems,  at  first,  to  balance 
the  absorbing  action,  and  the  part  remains,  to  appearance, 
the  same  ;  but,  after  a  little,  the  granulations  are  formed  faster 
than  they  are  absorbed  ;  the  ulcer  is,  therefore,  filled  up,  and 
the  excavation  obliterated.  When  the  ulcer  is  filled  up  to 
the  level  of  the  surrounding  parts,  or  nearly  so,  we  then  find 
the  action  of  increase  stop,  and  the  part  remain  stationary. 
This  depends  upon  the  original  laws  of  the  conformation  of 
the  system,  by  which  a  certain  structure  is,  in  every  part, 
produced  ;  and,  being  once  produced,  has  a  tendency  to  con- 
tinue. The  granulations  are  also  prevented  fiom  rising 
higher,  by  the  action  of  the  surrounding  parts,  of  a  similar 
nature,  each  portion  of  an  oigan  sympathising  with  the  rest, 
and  having  its  action  regulated,  to  a  certain  degree,  by  that 
of  the  rest.  It  is  owing  to  these  causes,  that  the  granula- 
tions, iu  a  healthy  ulcer,  c(o  7ioi  shoot  beyond  the  surface. 


188 

but  become  covered  with  skin,  the  skin-forming  action  of  the 
neighbouring  surface  spreading  to  the  ulcer,  whenever  it  be- 
comes nearly  level  with  it ;  that  is  to  say,  whenever  it  is  sus- 
ceptible of  receiving  this  communication  of  action.  The 
cicatrizing  process  begins  first  at  the  margins,  both  because 
the  depth  is  originally  less  there,  and,  therefore,  the  granula- 
tions sooner  rise  to  the  proper  level,  and  also,  because  they 
are  in  the  immediate  vicinity  of  the  sound  skin,  and,  conse- 
quently, have  the  action  first  communicated  to  them.  Some- 
times, indeed,  the  cicatrizing  action  is  assumed  by  different 
spots,  on  the  surface,  or  disk  of  the  ulcer ;  but,  in  this  case, 
it  is  frequently  diseased,  an  unhealthy  covering  being  pro- 
duced, which  soon  dies. 

The  cicatrix  is  at  first  thinner  and  softer  than  sound  skin, 
and  consists  only  of  one  layer,  called  cutis  ;  but,  afterwards, 
the  action  becomes  more  perfect,  and  both  cuticle  and  rete 
mucosum  are  produced.  This  gradation  toward  perfection, 
begins,  owing  to  the  communication  of  action,  at  the  margins  ; 
and,  therefore,  the  cicatrix  seems  to  grow  less  and  less,  or 
contract  itself,  owing  to  new  circles  of  perfect  skin  being 
slowly  formed. 

When  the  ulcer  is  unhealthy,  then  this  process  of  healing 
is  interrupted,  imperfect  granulations  are  thrown  out,  and  the 
cicatrizing  action  is  also  diseased,  a  thick  insensible  substance, 
called  callus,  being  formed  in  the  stead  of  thin  cutis.  The 
same  cause  which  affects  the  formation  of  the  granulations, 
affects  also  the  discharge,  which  becomes  different  from  what 
it  was  in  the  healthy  state,  being  sometimes  thicker,  but 
oftener  thinner. 

A  healthy  ulcer  is  not  attended  with  much  pain,  but  rather 
with  a  kind  of  smarting,  part  of  which,  perhaps,  may  be  at- 
tributed to  the  dressings,  or  other  causes,  acting  mechanical- 
ly on  it  :  But,  when  the  ulcer  becomes  unhealthy,  from  a 
change  in  the  action,  then  pain  is,  in  many  cases,  produced. 


189 

Suppuration  and  ulceration  are  actions  complete  in  them- 
selves, and  quite  different  from  the  inflammatory  one,  being 
no  otherwise  connected  with  it,  than  as  depending  upon  it 
originally  for  their  production.  Whenever  an  ulcer  assumes 
the  inflammatory  action,  then  the  ulcerative  action  subsides,* 
and  the  suppuration  lessens,f  in  a  degree  proportioned  to  the 
violence  of  the  inflammatory  action. 

The  ulcerative  action  consists  of  two  parts,  the  granula- 
ting and  the  purulent:  The  first  is  a  natural  action,  the  last 
a  morbid  one ;  but  these  two  are  so  connected,  as  to  render 
it  impossible  that  the  one  should  be  rendered  unhealthy,  with- 
out the  other  also  being  affected,  botli  conjoined  forming  a 
perfect  and  distinct  action,  different  from  the  inflammatory 
one  in  its  nature  and  consequences,  and  different  also  from 
the  suppurative  one  ;  for,  in  this,  no  granulations  are  formed, 
but  the  vessels  which  used  to  deposit  them,  secrete  a  fluid, 
or  purulent  matter.  These  actions,  although  distinct  from 
each  other,  may  yet  be  converted  the  one  into  the  other. 

The  inflammatory  action  naturally  terminates  in  the  suppu- 
rative ;J  and  this  may  either  continue  for  some  time  sta- 
tionary, and  then  terminate  in  the  ulcerative,  or  it  may  con- 
tinue to  increase.  In  the  first  case,  the  superficial  vessels  of 
the  abscess,  or  wound,  throw  out  pus,  whilst  those  immedi- 
ately below  it,  retain  nearly  their  natural  action,  or  form  or- 
ganic particles.     In  the  second  case,  one  layer  of  vessels 


*  The  term  ulcerative,  does  not  necessarily  imply  a  continuance  of  the  destruc- 
tion of  parts,  or  any  corroding  property,  otherwise  these  remarks  would  not  be 
just ;  for  inflammation  may  destroy  the  substance  of  the  ulcer,  and  make  it  larger, 
by  a  species  of  mortification,  although  the  ulcerative  action  be  injured  and  les*- 
>ened. 

f  This  has  been  observed  so  long  ago  as  the  days  of  Hippocrates,  w'.io  takes  no- 
tice of  the  bad  effects  which  follow  from  the  inflaming  of  wounds  in  ulcers:  "  Ig- 
neum  enira  fervorem  hoc  inducit,  ubi  honor  et  pulaatio  accesierit."  Dc  Ulct- 
ribus. 

\  The  suppurative  action  belongs  to  the  order  Glandulares  of  the  class 
Mixtio. 


190 

after  another,  if  I  may  use  the  expression,  assumes  the  sup- 
purative action,  and  the  excavation  increases,  from  the  loss 
of  power  to  form  organic  particles.  When  the  suppurative 
action  terminates  in  the  ulcerative,*  then  the  vessels  which 
used  to  form  organic  particles,  regain  their  naiural  action 
slowly,  and  one  after  another  ;  whilst  the  other  set  of  vessels, 
or  those  which  threw  out  interstitial  fluid,  yield  still  purulent 
matter.f  If  the  ulcerative  action  be  perfect  and  healthy, 
then  the  structure  of  the  part  is  slowly  renewed,  and  the  in- 
terstitial fluid  of  the  restored  part  becomes  natural ;  the 
quantity  of  pus,  therefore,  gradually  diminishes,  its  source 
being  lessened. 

If,  however,  from  any  cause,  the  ulcerative  action  should 
be  converted  into  the  suppurative,  then  granulations  are  no 
longer  formed,  and  the  part  either  remains  stationary,  or  the 
ulcer  spreads,  according  to  circumstances. 

Simple  ulcers,  or  ulcers  where  there  is  no  morbid  or  spe 
cific  action  conjoined  with  the  ulcerative,  may  be  divided  in- 
to five  genera,  which  consist  of  several  species  and  varieties, 
which  will  be  attended  to  in  considering  the  cure. 

First.  The  healthy,  or  healing  ulcer,  in  which  the  ulcera- 
tive action  exists  in  perfection. 

Second.  The  indolent  ulcer,  in  which  the  action  is  dimin- 
ished, and,  consequently,  rendered  more  or  less  imperfect. 

Third.  The  overacting  ulcer,  in  which  either  a  part,  or 
the  whole,  of  the  ulcerative  action  is  increased.  This  is  di- 
visible into  two  species  :  First,  when  only  a  part  of  the  ac- 
tion is  increased  ;  such  as  the  granulating,  forming  fungus  : 
Second,  when  the  action,  considered  as  a  whole,  is  increased, 
and  carried  on  with  greater  quickness ;  in  which  case,  the 


*  The  ulcerative  action,  when  simple,  belongs  to  the  order  Ulcerantes  of  the 
class  Mixta?. 

f  It  is  by  the  ulcerative  action  that  all  abscesses  are  healed,  and  that  all  loss  of 
substance  is  replaced: 


191 

granulations  are  formed  very  imperfectly,  and  with  very  little 
longevity  ;  the  discharge  also  is  changed. 

Fourth.  The  inflammatory  ulcer,  in  which  the  ulcerative 
action  is  changed  into  the  inflammatory. 

Fifth.  The  suppurative  ulcer,  in  which  the  ulcerative  ac 
tion  is  changed  into  the  suppurative.* 

The  symptoms  and  consequences  of  these  changes  will  be 
attended  to,  when  the  cure  comes  to  be  considered. 

It  has  been  supposed  by  some,  that  ulcers  healed  rather 
by  the  circumjacent  parts  sinking  down  to  the  level  of  the 
bottom  of  the  sore,  than  by  the  formation  of  granulations, 
and  the  renewal  of  the  lost  substance.  This  doctrine  was 
particularly  maintained  by  M.  Fabre,  a  French  surgeon,  who 
supposes  that  the  depth  of  an  ulcer  depends  chiefly  upon 
the  swelling  of  the  surrounding  parts,  and  very  little  upon 
the  real  loss  of  substance  ;  and,  therefore,  that  the  cure  must 
be  accomplished  chiefly  by  the  subsiding  of  the  neighbouring 
parls,  which  is  produced  either  by  amaigrissement  or  suppu- 
ration. When  the  parts  have  subsided  as  much  as  possible, 
then  a  cicatrix  is  formed,  which  is  somewhat  hollow,  or  con- 
cave, owing  to  the  loss  of  substance,  which  has  not  been  re 
newed  ;  but  this  hollow  soon  disappears,  owing  to  the  fatten 
ing  of  the  parts  below  it. 

This  doctrine  may,  in  part,  be  admitted  ;  for,  in  many 
cases,  we  observe  the  amaigrissement  of  the  parts  very  dis- 
tinctly. In  all  cases,  it  may  be  observed  to  a  certain  degree ; 
for,  in  every  instance,  a  swelling  at  first  accompanies  the  ul- 
cer ;  and  this  often,  although  not  always,  makes  it  appear  to 
be  deeper  than  the  real  loss  of  substance  would  occasion.  In 
extensive  ulcers  in  large  members,  we  also  observe,  tliat,  by 


*  These  two  last  genera  cannot  properly  be  called  ulcer?,  if  we  confine  this 
term  to  parts  possessed  of  the  ulcerative  action  ;  but  if  we  adhere  to  the  commou 
acceptation  of  the  word,  or  consider  them  merely  as  solutions  of  continuity, 
yielding  a  purulent  discharge,  ^hen  the  division  is  sufficiently  correct. 


192 

the  emaciation  of  the  part,  the  sides  approach  nearer  togeth- 
er, and  the  ulcer  is  healed  with  less  difficulty,  than  it  other- 
wise would  be ;  and  we  often  find  it  useful,  by  proper  banda- 
ges, to  assist  this  process.  But,  that  granulations  are  formed, 
and  that  they  are  the  chief  source  of  the  healing  of  the  ulcer, 
is  a  point  established  beyond  all  controversy,  and  which  may 
be  ascertained  by  looking  at  any  ulcer  on  the  tibia. 

Mr.  Hunter  supposes,  that  the  healing  of  an  ulcer  is  much 
accelerated,  by  what  he  calls  the  "  contraction  of  the  granu- 
lations." The  edges  of  the  ulcer,  he  imagines,  are  brought 
nearer  to  each  other,  by  the  granulations  contracting,  like  lit- 
tle muscles,  the  effect  of  which  is  increased,  by  some  of  the 
granulations  being  absorbed ;  in  consequence  of  which  the 
rest  fall  closer  together.  "  Besides,  the  contractile  power  of 
the  granulations,  there  is  also  a  similar  power  in  the  surround- 
ing edge  of  the  cicatrizing  skin,  which  assists  the  contraction 
of  the  granulations,  and  is  generally  more  considerable  than 
that  of  the  granulations  themselves,  drawing  the  mouth  of  the 
wound  together,  like  a  purse."* 

Were  granulations  to  contract  themselves,  by  any  muscu- 
lar power,  they  must  certainly  have  this  process  instantane- 
ously accelerated,  by  the  application  of  stimuli,  and  must  ex- 
hibit periods  of  relaxation,  which  they  are  not  observed  to 
do.  Were  the  contraction  of  the  sore  to  depend  upon  any 
power  of  the  margin  to  act  as  a  sphincter,  we  should  find,  that 
the  same  cause  ought  to  make  an  ulcer  consequent  to  a  cru- 
cial incision  larger,  and  prevent  it  from  healing  so  soon,  or 
with  so  small  a  cicatrix,  as  it  otherwise  would  do,  which  is 
not  observed  to  occur.  Were  the  contraction  to  depend  up- 
on interstitial  absorption  allowing  the  particles  to  fall  nearer 
each  other,  or  collapse,  by  the  power  of  gravity,  then  it  must, 
in  its  degree  and  effect,  be  regulated  entirely  by  the  perma- 

*  P.  4&4. 


193 

nent  posture  of  the  limb,  or  situation  of  the  ulcer;  for,  at  one 
time,  it  must  make  the  sides  fall  nearer  each  other,  and,  in 
opposite  circumstances,  they  must  recede  ;  but  this,  like  the 
former  occurrence,  we  do  not  observe. 

Granulations,  when  new-formed,  are  more  vascular,  and 
more  luxuriant,  than  afterwards ;  and,  therefore,  when  they 
become  more  natural,  or  less  spongy,  they  will  occupy  less 
space,  and  may  tend,  if  the  skin  be  relaxed,  to  bring  the  sides 
nearer  together,  by  their  condensation.  The  granulations, 
some  time  after  they  are  produced,  both  receive  less  blood, 
and  have  less  interstitial  fluid :  The  interstices  of  the  sore 
must,  therefore,  approach  nearer  together,  and  will,  by  the 
attractive  power  of  the  life  which  they  possess,  cohere  more 
firmly  together.*  They  likewise  possess  a  more  perfect  life 
than  at  first,  and,  therefore,  have  a  more  perfect  union.  On 
these  accounts,  the  disk  of  the  ulcer  may  be  lessened,  by  the 
approximation  of  its  different  particles.  The  sides  may  also 
approach  together,  in  extensive  ulcers  in  large  members,  by 
the  emaciation  of  the  parts,  which  lessens  the  diameter  of  the 
limb,  and,  consequently,  allows  the  skin  to  cover  more  of  the 
ulcer. 

The  contraction  of  the  superficies,  dependent  on  the  ope- 
ration of  these  causes,  is  different  in  degree,  in  different  in- 
stances. It  is  not,  however,  so  great  as  it  appears  at  first 
sight  to  be  ;  because  the  cicatrix,  which  is  first  formed  at  the 
margins,  is  very  thin  and  imperfect;  but,  in  a  short  time,  the 
action  becomes  more  perfect,  and  the  absorbed  matter  is  re- 
placed with  skin  more  exactly  resembling  the  neighbouring 


*  It  has  been  mentioned  in  the  preliminary  dissertation,  that  the  life  of  animals 
still  retains  the  property  termed  attraction,  and  which  belongs  to  the  vital  princi- 
ple of  matter,  from  which  it  is  derived.  It  was  likewise  mentioned,  that  this  pro- 
perty seems  to  be  increased,  by  the  elevation  into  a  higher  species  of  life.  It  is  by 
this  property,  that  the  different  parts  adhere  together ;  and  the  degree  of  adhesion 
depends  upon  the  quantity  and  perfection  of  the  life,  and  the  proximity  of  the  or- 
ganic particles  to  each  other. 

VOL.    I.  2    B 


194 

surface.     We,  therefore,  imagine,  that  the  old  skin  is  con 
tracting,  or  approaching  inward,  whilst  it  is  in  reality  the  new 
skin  which  is  becoming  similar  to  the  old. 

The  ulcerative  action,  chiefly  perhaps  in  consequence  of 
the  purulent  one,  Avhich  makes  a  part  of  it,  has  a  tendency  to 
affect  the  constitution,  and  induce  a  general  action,  called 
hectic.  The  symptoms  of  this  disease  are,  alternate  chills 
and  feelings  of  heat,  accompanied  by  a  frequent,  small  pulse, 
which  is  also  generally  at  first  sharp ;  by  loss  of  appetite, 
thirst,  diarrhcea,  colliquative  sweats  through  the  night,  ema- 
ciation of  the  body,  with  great  weakness :  The  urine  is  gene- 
rally pale.*  This  action  is  always  greatest  at  the  time  when 
the  natural  action  is  naturally  lowest,  namely,  in  the  evening  ; 
and  these  exacerbations  are  generally  preceded  by  chills  ;  for 
all  actions  which  are  renewed  at  stated  periods,  or  experience 
considerable  augmentations,  exhibit,  in  a  greater  or  less  de- 
gree, the  symptoms  of  the  period  of  formation.  This  action 
is  dangerous,  in  a  degree,  or  proves  fatal  with  a  rapidity,  pro- 
portioned to  the  quickness  with  which  it  is  induced  ;  and 
hence,  when,  by  any  cause,  it  is  speedily  produced  in  peo- 
ple who  previously  were  tolerably  healthy,  it  often  proves 
fatal  in  the  course  of  a  few  days.  I  have  known  a  man  die 
within  a  week  after  opening  a  lumber  abscess,  although,  at 
the  time  of  the  operation,  he  was  pretty  strong. 

This  disease  has  been  attributed  to  the  absorption  of  matter 
from  the  sore  ;  but,  when  we  consider,  that  the  hectic  is  not 
produced  by  sores,  wi'h  a  certainty  proportioned  to  their 
size  and  absorbing  surface,  but  is  dependent  chiefly  upon  the 
nature  of  the  part  affected,  and  the  specific  qualities  of  the 
local  action,  we  will  be  led  to  drop  this  opinion,  and  will  ra- 
ther ascribe  it  to  an  extension  of  the  action,  or  a  general 
mo.  bid  condition,  induced  sympathetically  by  it,  in  the  me- 


*  The  cheeks  are  also  generally  flushed  before  death. 


195 

tfood  already  mentioned,  when  treating  of  suppuration.  As 
a  confirmation  of  his,  it  is  to  be  remarked,  that  the  degree 
and  continuance  of  the  local  action,  and  he  nature  of  the 
part  affected  by  it,  have  the  chief  influence  in  producing 
the  hectic. 

The  same  causes  which  regulate  the  effect  of  the  inflamma- 
tory action  upon  the  constitution,  regulate  also  the  effect  of  the 
ulcerative  action.     When  this  action,  therefore,  takes  place 
in  the  lungs,  heart,  stomach,  joints,  &c.  then  the  hectic  is 
very  certainly  induced.     It  is  likewise  produced  by  the  long 
continuance  of  this  action,  if  extensive,  in  parts  which  are 
less  delicate,  and  which  do  not  act  quickly  upon  the  system ; 
such  as  the  cellular  substance ;  but  it  is  much  more  readily 
induced  in  the  former  case,  when  delicate  and  vital  parts 
are  injured.     The  peculiar  state  of  the  action  itself,  like- 
wise influences  the  production  of  this  disease  ;  for  healthy 
ulceration    is    less    apt   to   occasion   hectic,    than   the    dis- 
eased   or   unhealthy   "Ulcerative    action,    although,    in   both 
cases,    the  same    spot    be  affected.      Hence,    scrophulous 
ulcers    affect  the  constitution   more    than  many   others   of 
the  same  size ;  and  hence  also,  the  influence  of  the  exter- 
nal air    in    producing    hectic,    by    injuring   the   ulcerative 
action.     Whenever  an  agent  operates  on  any  part  which  is 
not  accustomed  to  its  action,  or  to  which  it  is  not  to  be  con- 
sidered as  a  natural  stimulus,  then  disease  is  produced,  or  the 
aciion  is  changed,  unless    he  power  of  the  agent  be  very  in- 
considerable.    The  air  is  to  be  considered  as  a  natural  sti- 
mulus only  to  the  lungs  and  surface  of  the  body  ;  and,  when- 
ever it  operates  on  any  other  part,  it  tends  to  injure  the  na- 
tural action  of  that  part.     When  atmospheric  air  is  taken  into 
the  stomach  or  bowels,  or  is  blown  into  the  cellular  substance, 
the  action  of  these  parts  is  slightly  injured  ;  when  introduced 
into  the  blood-vessels,  a  more  serious  evil  is  frequently  in- 
duced.    But  the  bad  effects  of  the  air  is  more  clearly  seen. 


196 

when  the  part  on  which  it  operates  is  previously  under  the 
influence  of  a  diseased  action.     The  suppurative  and  ulcera- 
tive actions,  are  merely  the  formative  actions  of  the  part,  or 
its  natural  action  rendered  morbid  ;  and  these  formative  ac- 
tions are  naturally  carried  on  without  the  presence  of  the  air, 
which  would  tend  to  impede  them  ;  but  it  will  operate  still 
more  visibly  and  powerfully,  in  changing  the  nature  of  the 
actions  into  which  they  are  transformed  by  disease,  render- 
ing these  actions  still  more  imperfect  and  unhealthy  ;  that  is 
to  say,  different  from  the  condition  which  enables  them  to 
terminate  again  in  the    natural    formative  actions,  by  the 
alteration    of    which    they    were     produced.      When  an 
abscess  is   opened,  and   the  air  thrown   in,    the  discharge 
becomes  thin  and  copious,  and   the  healing  process  is  in- 
terrupted.    When  an  ulcer  of  the  surface  is   exposed  long 
to  the  action  of  the  air,  then  it  becomes  foul  and  unhealthy.* 
When  an  abscess  of  an  internal  part,  or  cavity  of  the  body, 
is  opened,  or  bursts  externally,  so  as  to  allow  the  air  to  come 
in  contact  with  it,  then  the  constitution  becomes  affected,  the 
hectic  action  is  ushered  in  with  shiverings,  the  appetite  fails, 
and,  although  the  health  has  been  previously  good,  yet  the 
patient  often  dies  in  a  few  days. 

There  are,  then,  three  causes  which  tend  to  produce  hec- 
tic :  First,  the  existence  of  the  suppurative  or  ulcerative  ac- 
tion, in  delicate  or  vital  parts ;  and  this  tends  quickly,  at 
least,  comparatively  speaking,  to  induce  the  hectic  action. 
Second,  the  long  continuance  of  the  ulcerative  action,  to  a 
considerable  degree,  in  less  delicate  parts  ;  such  as  the  cellu- 
lar substance,  &c. :  This  acts  much  more  slowly  than  the 
other  causes.  Third,  the  specific  or  peculiar  qualities  of  the 
action  ;  such  as  scrophulous  action,  or  deviations  consequent 

*  This  change  of  the  ulcer  is  not  so  apt  to  produce  hectic,  as  a  similar  change  ol' 
the  internal  ulcers  or  abscesses;  because  the  one  naturally  produces  le=s  effer' 
upon  the  constitution  than  the  other. 


197 

to  the  action  of  the  air  upon  parts  where  it  is  to  be  consider- 
ed as  unnatural.  The  effect  of  the  qualities  will  be  much  in- 
creased by  the  nature  of  the  part  affected ;  for  the  same 
causes  operating  upon  ulcers  of  the  surface,  will  not  produce 
the  same  effect  on  the  constitution,  as  when  they  act  on  ulcers 
of  internal  and  vital  parts.  Hectic  will  likewise  be  sooner 
produced  in  those  who  have  an  irritable  habit,  than  in  those 
who  sympathise  less  quickly  and  less  easily. 

The  hectic  fever,  from  whatever  cause  it  may  be  induced, 
always  exhibits  certain  symptoms  which  are  essential  to  it, 
and  which  have  been  already  mentioned.  But,  in  addition 
to  these,  others  may  also  occur,  owing  to  the  peculiarly  of 
the  cause ;  and  perhaps  no  two  hectics  (induced  by  different 
causes)  are  exactly  similar  in  every  circumstance,  although 
the  difference  may  be  such  as  cannot  be  perceived  or  detect- 
ed. There  may  be,  for  instance,  and  undoubted!}'  is,  a  dif- 
ference in  the  hectic  induced  by  a  simple  ulcer,  from  that 
occasioned  by  a  scrophulous  one,  or  a  cancerous  one.  I 
have  seen  the  hectic,  or  diseased  formative  or  nutritive  ac- 
tion, accompanied  by  an  emphysema,  when  it  was  induced 
by  an  abscess,  which  had  an  emphysematous  action.  A  man 
had  a  seton  passed  through  a  tumor  on  the  neck,  but  very 
little  discharge  took  place  immediately.  In  the  course  of 
four  and  twenty  hours,  the  tumor  yielded  more  fluid,  which 
issued  along  with  a  bubbling  of  air ;  at  the  same  time, 
hectic  came  on,  and  air  was  extricated  into  every  part  of  the 
body.  He  died  within  two  days  after  being  taken  ill ;  and, 
on  opening  him,  I  found  air  contained  in  the  heart,  veins, 
scrotum,  and  every  cavity  of  the  body,  and  through  the 
whole  cellular  substance.  The  tumor  had  not  the  smallest 
communication  with  the  trachea ;  and,  therefore,  neither  the 
local  nor  general  emphysema,  could  be  attributed  to  Ihe  me- 
chanical introduction  of  atmospheric  air.     Here,  then,  was 


198 

an  instance  of  a  peculiar  modification  of  the  hectic,  owing  to 
the  peculiarity  of  the  local  action,  which  could  be  better  ob- 
served than  many  of  the  less  sensible  qualities. 

Mr.  Hunter  supposes,  that  hectic  is  a  diseased  state,  in- 
duced by  an  incurable  disease,  or,  "  a  constitution  now  be- 
come affected  with  a  local  disease,  or  irritation,  which  the 
constitution  is  conscious  of,  and  of  which  it  cannot  relieve  it- 
self, and  cannot  cure."*  But,  setting  other  arguments  aside, 
against  this  opinion,  we  find,  that,  in  very  irritable  people, 
abscesses  sometimes  produce  hectic,  for  a  week  or  two,  which 
goes  off  when  the  abscess  naturally  heals.  In  consequence 
of  this  opinion,  Mr.  Hunter  supposes,  that  the  affection  of 
the  constitution,  which  takes  place  when  a  sore  as,  for  in- 
stance, a  compound  fracture,)  has  gone  the  length  of  forming 
granulations,  that  is  to  say,  begins  to  cure,  is  not  true  hectic, 
but  a  disease,  which  he  calls  "  dissolution,"  by  which  he 
means  the  state  ushering  in  dissolution.  But  this,  I  appre- 
hend, from  the  view  which  has  been  given  of  the  subject,  will 
appear  often  to  differ,  in  no  respect,  from  hectic  ;  only,  it 
proves  fatal  sooner  than  this  disease,  in  some  other  instances, 
does.  At  other  times,  indeed,  the  sore  may  induce  the  state 
of  simple  weakness,  ushering  in  death,  without  hectic  ;  and, 
in  this  case,  the  term  "  dissolution"  may  be  sufficiently 
proper. 

There  are,  therefore,  two  states  which  may  be  induced  by 
inflammation,  and  both  terminate  in  death  ;  the  hectic  state, 
and  the  state  of  simple  weakness.  The  first  is  illustrated  by 
the  effect  of  ulceration  ;  the  second,  by  the  effect  of  inflam- 
matory fever.  It  is  merely  the  forerunner  of  death,  and, 
therefore,  will  succeed  almost  every  diseased  action.  But, 
although  it,  in  most  cases,  precedes  death,  yet  death  does  not 
universally  succeed  it ;  for,  as  will  be  immediately  mentioned,  it 

*  P.  497. 


199 

may  be  induced  by  the  sudden  cessation  of  actions,  when 
there  is  still  power  to  recover  by  proper  assistance. 

The  condition  of  the  body  immediately  before  death,  is, 
I  believe,  generally  that  of  simple  weakness,  unless  when  in- 
duced by  mortification,  or  similar  diseases,  as  will  be  present- 
ly mentioned.  It  is,  at  least,  so  far  a  state  of  simple  weakness, 
that  in  most  cases,  the  specific  diseases  disappear ;  and,  could 
the  patient  be  restored  to  strength  by  any  power,  he  would,  in 
all  probability,  be  free  from  the  peculiar  morbid  action  which 
formerly  existed.*  This  weakness,  as  Mr.  Hunter  has  ob- 
served, may  affect  one  part  of  the  body,  or  particular  func- 
tions, less  than  others.  On  this  account,  the  circulation  is 
often  carried  on  with  more  strength,  or  apparent  strength, 
than  is  proportioned  to  the  state  of  the  system ;  and,  there- 
fore, death  may  be  nearer  at  hand  than  we  would  imagine. 

In  the  preliminary  dissertation,  it  was  mentioned,  that  all 
actions  which  subside  suddenly  weaken  most.  This  state 
may,  therefore,  be  quickly  and  unexpectedly  induced,  by 
such  causes,  seen  or  hidden,  as  produce  a  sudden  diminution 
of  the  morbid  action.  It  may,  therefore,  take  place,  al- 
though the  patient  be  recoverable;  that  is  to  say,  although 
the  powers  of  life  be  not  absolutely  exhausted,  or  worn  out. 

If  long  continued  and  extensive  ulceration  be  productive  of 
injury  to  the  constitution,  by  exciting  a  general  action,  at- 
tended with  a  deviation  in  the  nutritive  action,  in  a  manner 
already  explained,  so  is  also,  in  many  instances,  the  sudden 
loss  or  absence  of  this  ulcerative  action  injurious.  If  the 
constitution  have  been  long  accustomed  to  this  secretory  ac- 
tion, the  stoppage  or  cessation  of  it  is  apt  to  induce,  in  some 
other  organ,  an  excretory  action,  although  of  a  somewhat  dif- 
ferent kind,  at  least  if  there  be  any  tendency  to  this,  on  ac- 

*  This  is  farther  confirmed,  by  observing,  that  this  state,  when  it  is  curable,  is  cured 
by  such  remedies  as  are  used  against  simple  weakness,  and  not  by  the  remedies 
which  vre  employ  against  the  specific  disease  which  produced  it. 


200 

count  of  age,  constitution,  &c.  Thus  the  hemorrhagic  action 
may  supervene,  upon  the  cessation  of  the  purulent  action,  and 
may  affect  either  the  brain,  lungs,  or  stomach,  according  to 
circumstances;  or  the  action  of  exhalation,  into  particular 
cavities,  may  be  produced,  giving  rise  to  hydrothorax,  asci- 
tes, &c.  These  effects,  however,  are  less  apt  to  be  produ- 
ced, if  hectic  have  been  induced  by  the  ulcer  before  it  was 
healed  ;  because  then  the  general  action  seems  to  diminish  the 
tendency  of  particular  parts  to  be  affected.  If  we  amputate 
on  account  of  a  large  ulcer,  the  patient  is  more  apt  to  become 
apoplectic,  if  he  has  had  no  considerable  degree  of  hectic, 
than  if  this  disease  has  made  a  greater  progress  ;  but,  at  the 
same  time,  if  we  have  allowed  it,  on  the  other  hand,  to  go  too 
far,  then  the  system  cannot  recover,  although  we  remove  the 
exciting  cause,  but  the  operation  will  rather  tend  to  accele- 
rate the  death. 

The  bad  effects  of  healing  old  sores,  without  proper  pre- 
caution, has  been  attributed  to  the  stoppage  of  a  quantity  of 
fluid,  which  produces  a  redundance,  or  plethora ;  and,  there- 
fore, "  adequate  drains,"  or  issues,  have  been  proposed ;  But, 
although  issues  may  be  proper,  in  many  cases,  to  prevent,  by 
the  continuance  of  an  ulcerative  action,  the  production  of  a 
secretory  action,  in  more  important  parts,  yet  it  does  not  fol- 
low, that  issues  act  by  draining  off  the  fluids,  as  Mr.  Bell  sup- 
poses, nor  that  the  healing  of  ulcers  produces  a  plethora.  If 
so,  we  must  produce  an  issue  almost  as  large  as  the  old  sore  ; 
at  least,  a  small  issue  will  do  no  good.  We  might  also,  by 
spare  diet,  abstinence  from  fluids,  bleeding,  purging,  &c.  pro- 
duce the  same  effect  with  an  issue,  which  nobody  expects 
will  be  the  case. 

Some  have  supposed,  that  when  old  sores  were  healed,  a 
peculiar  morbid  humour,  which  they  were  wont  to  discharge, 
was  retained  ;*  but  this  opinion  is  now  almost  abandoned. 

*  Morgagni  de  Sed.  et  Caus.  &c,  Epist.  LV.  a.  13. 


201 

Mortification.— Mortification,  strictly  speaking,  implied 
nothing  more  than  merely  death ;  but,  in  its  general  accepta- 
tion, it  is  made  also  to  comprehend  the  putrefaction  of  the 
part  which  is  killed ;  for,  as  the  dead  portion  still  adheres  to 
the  living,  until  this  process  takes  place,  the  putrefactive  fer- 
mentation has  been  always  considered  as  synonymous  with 
mortification,  and  as  constituting  one  of  its  necessary  symp- 
toms. This  disease,  then,  will  be  induced  by  whatever  can 
kill  the  part,  whether  by  subducting  directly  stimuli  necessa- 
ry for  life,  or  by  exciting  an  action  greater  than  the  power  of 
the  part  can  continue  to  perform.  An  instance  of  the  first 
we  have  in  the  effects  of  long  continued  cold,  compression 
of  the  arteries,  &c.  In  those  cases,  the  parts  being  de- 
prived of  necessary  stimuli,  die  slowly,  and  run  gradually 
into  the  putrefactive  fermentation.*  This,  however,  only 
happens  from  the  subduction  of  necessary  stimuli,  when  tire 
injuring  cause  is  very  powerful,  or  when  some  agent  excites 
an  action  afterwards  in  the  weakened  parts ;  in  which  case 
it  belongs  to  the  next  division,  which  is  illustrated  by  the 
effects  of  lightning,  inflammatior,  or  whatever  can  increase 
the  action  beyond  what  the  power  is  able  to  sustain. 

Mortification  is  most  likely  to  succeed  to  inflammation  in 
four  different  circumstances. 

First.  When  the  inflammation  is  very  violent  and  extensive, 
occurring  in  parts  which  were  formerly  healthly,  and  not  remark- 
ably delicate,  possessing  naturally  a  considerable  degree  of  ac- 


*  In  some  rare  instances,  the  part  becomes  quite  dry  and  hard,  constituting 
what  has  been  called  the  dry  gangrene,  to  which  tbe  epithet  white  1ms  been  added 
when  the  parts  preserved  their  colour.  The  term  gangrene,  however,  is  here  ira; 
properly  applied.  I  have  known  one  instance,  in  which  the  limb  became  cold,  in- 
sensible, and  quite  black,  but  not  dry.  It  evidently,  however,  was  not  gangre- 
nous; because  it  afterwards  recovered  its  power?,  to  a  certain  degree,  and  lost  th»> 
Hack  colour,  becoming  of  a  yellow  tinge. 

vol.  i*.  2t' 


202 

(ion,  as,  for  instance,  the  cellular  substance,  &c;  Mortifica- 
tion more    arely  takes  place  in  this  case. 

Second.  When  the  inflammatory  action  occurs  to  any  con- 
siderable degree  in  parts  where  the  action  is  naturally  little, 
as,  for  instance,  in  tendons,  &c. ;  or  where  it  ought  in  conse- 
quence of  previous  disease,  to  be  little,  as,  for  instanre,  in 
parts  which  have  been  weakened  by  cold,  or  in  people  who 
have  had  fever  or  palsy,  ike. 

Third.  When  the  inflammatory  action  affects  parts  which 
are  naturally  very  sensible,  and  very  susceptible  of  having 
action  easily  induced  in  them,  such  as  the  intestines,  the 
cutis,  &c. 

Fourth.  When  the  inflammatory  action  is  complicated 
with  some  other  morbid  condition,  being  produced  by  one  of 
the  agentes  dissimiles,  such  as  pestilential  carbuncle,  &c* 

Mortification  may,  in  one  point  of  view,  be  compared  to 
the  natural  process  of  the  dissolution  and  absorption  of  the 
different  parts  of  the  body,  the  organic  particles  of  which 
enjoy  a  longer  or  shorter  life,  according  to  the  power  which 
they  originally  received,  and  the  strength  and  nature  of  the 
agents  which  operate  on  them.  When  these  particles  are, 
from  the  very  first,  weak,  a  small  stimulus  must  soon  destroy 
the  little  life  which  they  possess,  and  their  longevity  will  na- 
turally be  shorter,  even  although  no  disproportionate  ac- 
tion be  excised  in  them.  The  same  law  which  ^prevails 
with  regard  to  these  particles,  obtains  also  in  the  larger  por- 
tions of  the  body;  for  a  degree  of  inflammation,  easiiy  sus- 
tained by  a  strong  part,  will  destroy  the  same  part,  if  it  has 
been  previously  weakened.     The  chief  difference  betwixt 


•  Some  gangrenous  affections  are  epidemic,  whilst  others  are  endemic.    Mor- 
gagni  mentions  from  Brunnerus,  a  particular  gangrene  of  the  legs,  to  which  the  in- 
habitants of  the  Black  Forest  were  subject,  and  which  they  were  willing  to  attri 
'bute  to  the  use  of  bad  rye.    £pist.  LV.  a.  24. 


203 

these  processes  is,  that,  in  the  one  case,  the  particles  are  ab- 
sorbed, and  immediately  replaced,  whilst,  in  the  other,  from 
the  magnitude  and  degree  of  the  destruction,  and  the  exten- 
sion of  the  loss  of  all  vital  action,  the  part  cannot  be  absorb- 
ed, but  remains,  and  putrifies.*  Both  processes  likewise  re- 
semble each  other,  in  this,  that  the  death  is  dependent  upon 
an  action  of  the  vital  principle,  which  has  this  for  iis  object. 
Death  has  been  considered  as  merely  a  privation  of  life,  or  a 
cessation  of  action ;  but  this  negative  state  docs  not  consti- 
tute absolute  death.  Death  is  the  descending  of  the  vital 
principle  of  one  species,  to  the  condition  of  that  of  another 
of  a  lower  degree,  and,  therefore,  must  imply  activity,  or  a  state 
of  change  and  conversion,  referable  to  an  action  of  the  vital 
principle  itself.  There  is,  however,  this  intimate  connexion 
betwixt  a  cessation  of  action,  or  apparent  death,  and  real  or 
absolute  death,  that  when  the  vital  principle  is  not  employed 
in  some  o  her  action,  it  has  a  natural  tendency  to  assume  the 
action  of  descent,  or  sink  down  to  a  lower  species.  This 
descent  would  appear  to  take  place  more  or  less  rapidly,  ac- 
cording to  the  absolute  quantity  of  life  which  exists  together, 
in  the  oigan  or  part  which  is  to  die  ;  for  wherever  the  quan- 
tity is  very  small  before  the  action  of  descent  commences, 
then  it  takes  place  very  quickly.  Hence,  when  a  number  of 
organic  particles  are  contained  in  any  portion,  and  have  their 
life  strong,  and  in  due  quantity,  then  they  retain  it  for  a  consi- 
derable time,  and  descend  only  very  slowly,  at  the  same  time 
that  they  are  absorbed  and  converted  by  the  living  power  of 
the  vessels  which  take  them  up,  into  a  substance  different 


*  When  a  particle  dies  in  a  healthy  part,  or  in  an  action  of  a  part,  then  the  ab- 
sorbents change  it  into  a  peculiar  fluid,  by  an  action  of  their  vital  power  :  But 
when  a  great  number  of  particles  die  at  once,  in  the  immediate  vicinity  of  each 
other,  nnd  the  absorbents  have  their  action  suspended,  and  begin  themselves  to  die 
ilien  the  part  cannot  be  absorbed  or  changed  into  a  fluid,  by  the  vital  power  Of, 
the  animal,  but  it  remaius,  and  undergoes  the  putrefactive  fermentation,  as  wjH 
afterward?  be  meulioncd. 


204 

from  their  former  condition.  But  if  their  life  be  in  too  small 
quantity,  or  only  a  few  insulated  particles  be  taken  to  act  on, 
then  the  descent  takes  place  quickly.  Hence,  if  we  kill  an 
animal  instantly,  and  cut  out  a  muscle,  it  will  retain  its  animal 
life  much  longer,  if  the  animal  be  healthy  and  strong,  than  if 
it  be  weak  and  diseased.  Hence  likewise,  an  animal  will 
putrify  soonest,  if  it  die  from  the  action  of  any  of  the  agentes 
dissimiles,  than  from  other  causes  ;  or,  in  other  words,  the  in- 
terval betwixt  apparent  and  real  death  is  shorter.  An 
amputated  limb  of  a  strong  man  will  longer  exhibit  contrac- 
tion, by  the  application  of  the  zinc  and  silver,  than  the  limb 
of  a  man  who*  labours  under  plague,  or  cynanche  maligna, 
were  amputation  to  be  performed  in  these  diseases  ;  because, 
in  the  one  case,  there  is  more  real  animal  life  remaining,  at 
the  time  of  cessation  of  evident  action,  or  apparent  death, 
than  in  the  other  ;  and,  therefore,  the  action  of  descent  takes 
place  more  slowly,  and  real  death  is  longer  of  being  produced. 
This  descent  may  be  accelerated,  after  apparent  deaih,  by 
such  causes  as  tend  to  destroy  still  more  the  remaining  vitali- 
ty) by  exciting  an  action  in  it,  although  this  action  be  not  at- 
tended by  coniraction,  or  other  mechanical  and  very  evident 
effects.  Electric  shocks,  heat,  putrid  matter,  tossing  about, 
&c.  will  hasten  this,  and  induce  the  putrefactive  fermentation, 
which  does  not  take  place  in  the  solid  fibre,  until  the  descent 
be  produced  ;  because  no  such  extensive  chemical  changes, 
and  new  arrangements  or  combinations,  peculiar  to  common 
matter,  can  take  place,  as  long  as  animal  life  remains.  But, 
although  the  muscular  fibres  of  the  muscle  will  not  putrify, 
until  real  death  take  place,  yet  the  interstitial  fluid,  which 
has  less  life,  and  consequently,  dies  soonest,  may  begin  to  un- 
dergo this  process,  before  the  fibres,  or  solid  and  organized 
part,  be  dead  ;  but,  almost  immediately  afterwards,  the  whole 
dies  ;  because  putrid  matter  tends  to  destroy  animal  life ; 
and,  therefore,  the  interstitial  fluid  in  the  muscle  hastens  the 


205 

death  of  the  fibre.  Hence,  ceteris  paribus,  the  less  inter- 
stitial fluid  that  a  part  has,  the  longer  will  it  live  ;  because 
then  one  agent,  tending  quickly  to  excite  universal  descent 
of  vitality,  is  absent. 

We  may,  from  these  remarks,  understand,  first,  why  a 
part  which  dies  in  consequence  of  inflammation,  should  pu- 
trify  much  sooner  than  the  same  part,  if  cut  out  of  the  body 
in  health,  and  kept  equally  hot ;  because  the  quantity  of  life, 
before  apparent  death  takes  place,  is  very  small :  Second, 
why  the  mortification  tends  to  spread,  even  independent  of 
the  continuance  of  its  cause,  or  inflammation  ;  for  the  putrid 
matter,  which  is  already  generated,  tends  to  excite  a  fatal  ac- 
tion in  the  surrounding  parts,  and  is  to  be  considered  as  an 
agens  dissimilis.  If  putrid  matter  be  applied  to  a  wound, 
that  wound  never  heals  without  sloughing. 

The  bad  effects  of  mortification  on  the  system,  are  not  to 
be  attributed  altogether  immediately  to  the  original  inflamma- 
tory action,  or  to  the  fever,  overpowering,  as  it  were,  the 
constitution  ;  because  we  often  find  these  continue  much 
longer,  and  equally  violent,  where  no  mortification  takes 
place,  without  the  same  injury  being  produced.  It  has  been 
already  mentioned,  that  all  local  actions  have  a  tendency, 
sooner  or  laier,  to  extend  themselves,  and  produce  a  general 
disease.  The  suppurative  and  ulcerative  action  produces 
hectic,  in  a  way  which  has  been  formerly  explained.  In  the 
^pame  way,  local  mortification  tends  to  induce  a  general  and 
very  dangerous  disease,  exciting  that  general  state  which  we 
find  induced  by  the  application  of  putrid  matter  to  delicate 
or  divided  parts,  and  inducing  the  tendency  to  the  action  of 
descent,  on  account  of  the  peculiar  nature  of  the  local  ac- 
tion.*"    This  general  disease  is  also  sometimes  induced,  by 

*  That  the  danger  arising  from  mortification  is  owing  to  the  sympathetic  exten- 
sion of  the  local  action,  and  not  to  the  absorption  of  putrid  matter,  and  a  general 
>'  depravation  of  the  fluids,"  is  evident,  from  this  circumstance,  amongst  many 


206 

the  action  of  an  agens  dissimilis,  which  operates  on  the  sys« 
tern,  at  the  same  time  that  the  local  action  is  produced,  and 
may,  in  this  case,  be  said  to  be  idiopathic.  This  is  illustra- 
ted by  cynanche  maligna.  The  induction  of  this  general 
state,  is  one  great  cause  of  the  rapidity  with  which  gangrene 
sometimes  spreads  ;  because,  if  I  may  use  the  expression,  it 
prepares  the  parts  for  its  reception.  It  diminishes  the  quan- 
tity of  life  and  of  natural  action,  and  tends  to  induce  the  ac- 
tion of  descent,  in  every  particle.  Very  slight  causes,  then, 
will  make  a  number  of  particles  die  at  once.  Hence,  the 
local  action  can  spread  with  ease. 

The  local  action  is  marked  by  Iividity  of  the  parts,  which 
gradually  become  black  ;  the  cuticle  rises  up  into  blisters, 
and  an  abominable  smell  is  produced  ;  the  mortified  part  is 
quite  cold  and  insensible  ;  but  the  parts  which  are  only  as- 
suming the  gangrenous  state,  and  which  may  still  be  said  to 
be  inflamed,  are  extremely  painful,  because  the  action  is 
much  greater  than  the  power. 

The  general  action  is  marked  by  great  frequency  and 
feebleness  of  the  pulse,  unusual  weakness,  which  rapidly  in- 
creases ;  by  thirst,  squeamishness,  foul  tongue,  and  teeth 
covered  with  sordes  ;  heavy  languid  eye,  and  sharp  anxious 
features.  Before  death,  the  urine  and  stools  frequency  come 
away  involuntarily,  and  the  patient  lies  in  a  kind  of  comatose 
slumber.  At  the  same  time,  the  action  of  descent  commen- 
ces, wherever  the  lite  is  lowest  ;  and,  owing  to  this,  many 
of  the  animal  excretions  become  foetid.  Sloughs  also  are 
formed,  where  the  operation  of  foreign  agents  is  greatest,  as, 
for  instance,  where  the  pressure  opperates  most>  as  on  the 

others,  that  the  general  action  is  greater  when  the  local  action  affects  delicate 
parts,  with  which  the  rest  of  the  system  sympathises  rapidly,  than  when  it  affects- 
other  parts,  although  in  both  cases  the  absorption  may  be  supposed  to  be  alike. 


207 

shoulders,  hips,  &c.#  Before  death,  the  pulse  sometimes 
becomes  full  ;  but  then  the  artery  has  almost  lost  its  power, 
and  become  similar  to  a  vein,  with  respect  to  contraction. 
We  feel  it  rather  moving  than  beating,  and  it  is  impractica- 
ble to  count  any  regular  pulsation.  When  this  happens, 
it  is  impossible  that  recovery  should  take  place. f 

It  has  been  supposed,  that  mortification  was  produced  by 
some  peculiar  acrimony  of  the  fluids, £  or  putrid  ferment. 
Others  maintain,  tliat  it  is  produced  by  the  violence  of  the 
action  of  the  vessels,  which  throw  out  red  blood  in  place  of 
serum  ;  and  that,  as  this  red  blood  cannot  be  converted  into 
pus,  it  putrifies,  and  causes  gangrene.  5  But  these  doctrines 
overlook  the  peculiar  action  of  the  living  principle,  and  attri- 
bute to  the  changes  of  the  fluids,  that  which  really  belongs 
to  the  operations  of  life.  The  generation  of  putrid  matter, 
has  been  too  often  considered  as  a  cause,  and  not  a  conse- 
quence of  disease.  The  humoural  pathology  has  even  been 
carried  so  far,  that  it  has  been  maintained,  that  the  blood  it- 
self might,  by  some  causes,  become  putrid,  and  thus  excite 
diseases.  But  if  blood  be  necessary  for  the  continuance  of 
life,  what  must  we  think  of  the  theory,  which  talks  of  so 
complete  a  destruction  and  change  of  this  fluid,  as  putrefac- 
tion must  produce,  and  yet  allows  that  the  patient  lives,  and 
supports  a  diseased  state  !     That  the  blood,  like  the  rest  of 


*  Tulpius  records  an  instance  of  universal  gangrene,  or  mortification,  which  af- 
fected the  whole  body.  Obs.  Med.  Lib.  III.  c.  46.  Many  similar  instances  are 
on  record. 

t  In  mortification,  no  one  ever  recovered  from  this  state  ;  because  the  action  of 
descent  is  then  very  nearly  induced,  and  the  tendency  to  it  is  so  great  now,  that, 
independent  of  the  correspondent  weakness,  recovery  is  impossible.  But,  when  this 
state  is  induced  by  some  other  specific  disease,  such  as  fever,  it  is  possible,  though 
barely  so,  for  recovery  to  take  place  ;  for,  in  this  case,  the  specific  disease  i«  most 
probably  gone,  and  simple  weakness  alone  remains,  as  has  been  mentioned,  when 
treating  of  the  prelude  to  dissolution. 

X  Valsalva  tells  us,  that  the  serum,  in  a  case  of  mortification,  was  so  acrid,  that 
•when  he  tasted  it,  his  tongue  smarted,  for  a  whole  day. 

f  Bell  on  Ulcers,  p.  100. 


208 

the  body,  may  be  reduced  to  such  a  state,  as  to  putrify  very 
quickly,  after  being  drawn,  or  after  apparent  death,  is  evident, 
and  will  be  easily  understood,  from  what  has  already  been 
said  ;  but  this  is  very  different  from  a  putrefaction  of  the 
blood,  when  circulating  in  the  living  body,  and  a  consequent 
disease. 

Of  the  Modifications  of  the  Inflammatory  Action  produced 
by  the  Nature  of  the  Affected  Part. 

In  the  course  of  this  dissertation,  it  has  been  mentioned, 
that,  in  many  instances,  the  symptoms  of  inflammation  are 
modified  by  the  state  of  the  part  which  it  attacked.  In 
some,  the  swelling  is  greater  than  in  others  :  Some  parts  are 
much  more  pained,  and  some  feel  much  hotter  than  others. 

In  the  brain,  inflammation  produces  simple  pain,  without 
heat,  a  feeling  of  tightness  and  confusion,  aggravated  during 
the  diastole  of  the  artery.  The  eyes  are  red  and  ferocious, 
or  unsettled,  and  very  sensible  with  respect  to  light.  These, 
symptoms  proceed  from  the  connexion  betwixt  the  eye  and 
brain,  by  means  of  the  short  optic  nerve.  The  intellectual 
senses  are  impaired,  and  the  power  of  supporting  ourselves 
in  an  erect  posture  is  lost.  The  brain  is  rendered  redder  by 
inflammation,  and  more  turgid.  The  formation  of  organic 
particles  is  less  affected  than  in  many  other  parts ;  and, 
therefore,  the  intimate  structure  of  the  inflamed  part  is  less 
altered ;  but  still  there  is  a  change  produced,  the  matter  being 
tougher,  and  more  like  polypus.  The  terminations  are  either 
resolution,  or  gangrene,  (in  which  case  the  portion  becomes 
softer  and  thinner,  and  of  a  more  dusky  colour,  or  black, 
where  there  are  membranes,)  or  suppuration  ;*  in   which 


*•  If  suppuration  does  not  take  place,  either  the  interstitial  or  the  exhalent  fluifv 
is  thrown  out  in  greater  quantity,  and  dropsy  is  produced. 


209 

case,  a  thick  yeUow  pus  is  formed,  and  coma  is  produced. 
If  this  abscess  be  opened,  the  patient  sometimes  recovers, 
and  the  ulcerative  action  commences.  The  granulations  are 
red,  and  very  vascular,  which  we  learn,  by  finding  them,  after 
death,  to  be  of  a  dark  bloody  colour.  The  pulse  is  always 
quickened,  and  becomes  hard ;  but  its  condition,  with  re- 
spect to  fullness  and  smallness,  is  uncertain. 

When  the  eye  is  inflamed,  the  vessels  become  red  and 
turgid ;  but  the  eye  itself  does  not  become  larger.  The  sen- 
sation is  partly  that  of  a  foreign  body  being  in  it,  and  partly 
of  heat,  or  the  same  uneasy  itchy  sensation  which  heat  pro- 
duces, when  it  acts  on  the  eye.  The  termination  is  general- 
ly an  increased  secretion  of  exhalent  fluid. 

The  inflammation  of  the  tonsil  produces  swelling,  redness, 
and  the  sensation  of  simple  pain,  with  very  little  heat.  If, 
however,  the  action  has  been  chiefly  confined  to  the  cover" 
ing  of  the  tonsil,  or  has  been  erysipelatous,  then  there  is  a 
sensation  of  heat  and  dryness.  Any  of  the  terminations 
may  take  place  here  ;  but  that  of  gangrene  is  very  rare  in 
simple  inflammation.  When  suppuration  or  ulceration  take 
place,  then  the  quantity  of  exhalent  fluid,  which  is  slightly 
changed,  is  increased,  and  the  mouth  is  filled  with  a  tough 
slaver.  When  the  internal  part  suppurates,  or  the  surface 
ulcerates,  thick  yellow  pus  is  formed.  Sometimes  the  super- 
ficial vessels  throw  out  a  thick  yellow  substance,  like  coagula- 
ted lymph,  (owing  to  a  slight  excoriation,)  producing  specks. 
The  pulse  is  quickened,  but  is  not  in  general  very  hard, 
Sometimes  it  seems  to  be  quickened,  rather  by  the  simple  ir- 
ritation, or  pain,  than  by  the  sympathetic  fever,  and,  in  this 
case,  it  is  soft. 

Inflammation  in  the  chest  produces  acute  pain,  aggravated 
at  each  inspiration.     The  sensation  of  heat  is  very  moderate; 

vol.  r.  2  d 


210 

The  terminations  take  place  without  any  peculiarity.*  The 
pulse  is  hard  and  full,  if  the  inflammation  be  moderate  ;  but 
if  it  be  excessive,  or  if  it  occur  in  weak  people,  the  pulse  is 
smaller. 

Inflammation  of  the  trachea,  urethra,  nostril,  &c.  produces 
a  sensation  of  smarting,  with  a  slight  degree  of  heat.  The 
natural  discharge  is  increased  in  quantity,  and  rendered 
thicker,  and  yellow.  When  this  happens,  the  pain  abates. 
If  the  inflammation  be  more  violent,  then  this  termination  does 
not  take  place,  but  the  parts  become  more  turgid  and  painful ; 
the  exhalent  fluid,  or  natural  discharge,  is  either  obstructed, 
or  is  thrown  out,  like  the  interstitial  fluid,  thick  and  changed, 
as  in  other  parts,  forming  a  lining  to  the  canal.  If  the  in- 
flammation be  still  more  violent,  then  the  organic  particles 
also  are  affected,  and  become  imperfect,  or  ulceration  takes 
place. 

When  the  stomach  is  inflamed,  the  pain  is  generally  acute, 
and  often  of  the  burning  kiiiu ;  whilst,  from  the  increased 
sensibility  of  the  stomach,  every  thing  is  thrown  up.  The 
pulse  is  small  and  hard  :  The  anxiety  and  oppression  are 
great.  The  termination  which  is  most  likely  to  take  place, 
is  gangrene. 

Inflammation  of  the  small  intestines  produces  nearly  the 
same  symptoms,  only  the  vomiting  is  not  so  excessive.  The 
heat  is  always  considerable,  and  often  excruciating,  as  we  ob- 
serve in  those  who  take  arsenic.  When  the  great  intestines 
are  inflamed,  the  heat  is  commonly  less ;  and,  if  the  inflam- 
mation be  slight,  it  is  even  not  at  all  perceived.  The  pain, 
however,  is  acute,  and  generally  of  the  lancinating  kind.  The 
pulse  is  frequent  and  hard,  but  not  so  contracted  as  when  the 
small  intestines  are  affected.  The  termination  most  frequent- 
ly is  gangrene,  if  resolution  be  not  obtained ;  but,  in  some 

*  Auhcsioa  is  the  most  frequent  termination. 


i 

n 


211 

cases,  suppuration  and  ulceration  take  place,  which  is  sel- 
dom, if  ever,  the  case,  when  the  small  intestines  are  inflamed. 
The  intestines  may  also  have  their  internal  surface  chiefly 
affected;  in  which  case,  they  are  similar  to  the  urethra,  &c. 
only  the  system  suffers  more.  This  is  productive  of  a  dy- 
senteric affection,  or  increased  discharge  of  thin  slime,  and 
consequently,  is  less  dangerous  than  inflammation  of  the  peri- 
toneal covering,  or  of  the  whole  substance,  without  this  se- 
cretion. The  same  effects  are  produced  in  the  bladder ;  for 
if  its  internal  surface  be  chiefly  affected,  then  the  termination 
is  most  commonly  an  increased  discharge  of  the  slime ;  but 
if  the  whole  substance  be  affected,  then  gangrene  or  suppura- 
tion is  piifrluced.  The  organic  particles  and  interstitial  fluid 
are  more  affected  than  in  the  intestines ;  for  we  find  a  thick- 
ening produced ;  and  within  the  pores  of  the  thickened  sub- 
stance, there  is  a  gelatinous  fluid,  which  is  the  changed  inter- 
stitial fluid. 

When  bones  are  inflamed,  the  nature  of  the  organic  parti- 
cles is  changed,  and  they  become  much  softer:  The  intersti- 
tial fluid  is  also  altered,  and  resembles  thin  fat  soup.  W*~*» 
this  flows  out,  they  are  said  to  suppurate.    The  pain  is  great. 

When  cartilages  or  tendons  are  inflamed,  the  pain  is  like- 
wise great.  The  part  swells,  and  becomes  redder,  and  more 
pake,  losing  the  shining  appearance ;  and  the  interstitial  fluid 
grows  rather  thicker.  When  suppuration  takes  place,  the 
pain  does  not  abate  so  much  as  in  some  other  parts  ;  because 
the  action  still  is  greater  than  the  natural  power  of  the  part 
would  produce.  Inflammation  here  may  also  produce  sloughs 
or  gangrene. 

Inflammation  of  membranes  is  also  very  painful :  Their  ap- 
pearance, from  the  change  of  the  nature  of  the  organic  parti- 
cles, is  always  altered :  They  uniformly  become  thicker  and 
more  opake  ;  and  this  structure  they  often  retain,  after  the 
inflammation  goes  off,  as  we  see  in  the  lurid  cornea  of  the  eye. 


212 

When  muscles  are  inflamed,  they  swell ;  the  organic  parti- 
cles are  in  part  affected ;  the  interstitial  fluid  becomes  thick- 
er, and  the  power  of  motion  is  greatly  diminished.  The  most 
frequent  termination  here  is  a  secretion  of  the  interstitial  fluid, 
similar  to  that  in  health,  but  in  rather  greater  quantity.*  If, 
however,  the  inflammation  has  been  more  violent,  which  sel- 
dom happens  in  rheumatism,  owing  to  the  diffusion  of  the  ac- 
tion, then  the  suppurative  action  is  produced,  as  we  observe 
in  wounds,f  &c.  The  sensation  is  more  of  the  wringing  or 
pricking  kind,  than  of  heat  or  warmth,  although  there  some- 
times be  a  kind  of  confused  sensation,  or  resemblance  to 
warmth. 

The  peculiarities  of  glandular  inflammation,  with  regard  to 
suppuration,  have  been  already  mentioned.  They  have,  hj 
general,  a  considerable  tendency  to  this  termination  ;  and, 
therefore,  it  is  more  difficult  to  have  the  inflammation  resolv- 
ed ;  but  the  same  cause  makes  it  almost  impossible  for  gan- 
grene to  take  place.  The  pain  is  generally  pricking,  or  lan- 
cinating, although  in  some  particular  glands,  as,  for  instance, 
the  testicle,  it  is  more  of  the  gravitating  kind. 

When  the  cellular  substance  is  inflamed,  the  swelling"  is 
considerable,  and  the  sensation  chiefly  that  of  tension,  or  the 
same  as  if  a  person  were  rudely  handling  a  very  delicate  part ; 
but  when  the  cutis  becomes  affected,  the  redness  is  great, 
and  the  feeling  of  heat  very  acute.  All  the  terminations  of 
inflammation  may  take  place  in  the  cellular  substance ;  but 
the  inflammation  of  the  cutis  generally  ends  either  in  a  slight 
discharge  of  perspirable  matter,  followed  by  a  desquamation 
of  the  cuticle,  or  in  gangrene. 


*  When  a  muscle  is  inflamed  at  the  time  of  death,  we  find  the  interstices  full 
of  a  lymphatic  interstitial  fluid. 

t  Wounds  likewise  act  by  suddenly  producing  a  void,  which,  as  has  been  alrea- 
dy mentioned,  excites  the  purulent  action,  even  with  a  very  moderate  degree  of 
previous  inflammation. 


213 

These  modifications  of  simple  inflammation,  dependent  on 
the  nature  of  the  part  affected,  are  likewise  affected  by  spec! 
fie  modifications  of  the  inflammatory  action  itself.  Some  of 
these  induce  ulceration  in  every  part  indiscriminately.  Some 
never  end  in  suppuration.  Others  tend  chiefly  to  produce 
mortification.  Some  are  attended  with  the  sensation  of  heat 
more  than  others,  Kr. 


ESD  of  vol.  i. 


I 


DISSERTATIONS 

ON 

INFLAMMATION, 


DISSERTATION  II. 

CONTINUED. 
UN  SIMPLE  INFLAMMATION,   AND  ITS  CONSEQUENCES 


Of  the  Cure  of  Inflammation. 

IN  attempting  the  cure  of  inflammation,  or  its  consequen- 
ces, we  must  naturally  be  directed  to  the  means  of  removal 
by  the  nature  of  the  action  itself,  and  the  object  which  we 
have  in  view.  The  treatment  of  the  inflammatory  action 
may  be  considered  in  two  points  of  view ;  first,  as  this  action 
consists  in  peculiar  changes  of  the  natural  action,  which 
changes  we  wish  to  remove;  and,  secondly,  as  this  action  na- 
turally tends  to  disappear,  and  produce  other  actions,  which 
require  a  peculiar  treatment.  The  observations,  therefore, 
which  are  to  be  made  upon  the  method  of  cure,  may  be  ar- 
ranged under  the  heads  of  the  different  terminations  of  in- 
flammation. 

Of  the  Treatment  necessary  to  procure  Resolution. 
In  the  treatment  of  most  wounds,  our  chief  intention  is  to 
prevent  the  accession  of  inflammation,  and  procure  adhesion; 

VOL.    II.  A 


which  is,  in  one  respect,  analogous  lo  resolution.  When  in 
flammation  has  taken  place,  either  in  wounds,  or  in  other  ca- 
ses, our  great  object  is,  to  remove  or  lessen  it  as  quickly  as 
possible,  which  we  effect,  first,  by  removing  the  exciting 
causes  of  inflammation,  or  such  causes  as  tend  to  increase  the 
action  ;  and,  secondly,  by  applying  such  remedies  as  tend 
directly  to  abate  the  inflammatory  action. 

Upon  the  propriety  of  removing  the  exciting  causes,  and 
the  manner  of  doing  so,  very  little  requires  to  be  said.  If  any 
acrid,  or  stimulating  substance,1  has  been  applied  to  the  skin, 
or  any  extraneous  body  been  forced  into  it,  these  must  be 
removed  before  the  inflammation  can  be  resolved  ;  because, 
if  they  be  allowed  to  remain,  they  will  keep  up  the  action  so 
long,  and  to  such  a  degree,  that  suppuration  will  be  produc- 
ed, or  gangrene,  if  the  part  be  very  sensible,  (as,  for  instance, 
the  cutis;  or  if  the  exciting  cause  be  very  irritating.  Acrid 
substances  are  to  be  removed  by  ablution  with  water,  which 
is  in  general  much  better  than  the  solutions  which  are  pro- 
posed upon  the  principle  of  chemically  combining  with  the 
acrid  ;  because  these  generally  are  likewise  acrid,  or  stimu- 
lating, and  increase  still  more  the  inflammation  which  has  ta- 
ken place,  before  they  can  combine  with  the  substance  which 
was  formerly  applied,  and  become  neutralised.  This  may  be 
illustrated  by  the  operations  of  acids  and  alkalis.  If  heat 
have  been  applied,  so  as  to  induce  inflammation,  we  must  re- 
move the  superabundant  quantity  of  heat,  but  must  not  apply 
cold  ;  because  we  then  do  mischief,  as  will  be  afterwards 
mentioned. 

When  a  substance  is  forced  into  the  skin,  so  as  to  stimulate 
mechanically,  we  must  endeavour  to  lay  hold  of  it,  and  pull  it 
out ;  but  if  it  have  penetrated  so  deep  as  to  make  this  imprac- 
ticable, we  must  then  enlarge  the  wound,  and  remove  it ;  be- 
cause we  thus  may  enable  the  wound  to  heal  by  the  first  in> 
tent  ion.     If,  however,  the  injury  done  be  great,  if  the  part 


5 

be  much  bruised,  or  the  extraneous  substances  be  numerous, 
we  may  be  less  anxious  about  the  extraction  of  such  as  require 
much  trouble  ;  because  the  irritation  which  is  thus  given  will 
tend  to  increase  the  degree  of  inflammation,  and,  very  proba- 
bly, its  extent,  at  the  same  time,  that  from  the  original  inju- 
ry there  is  little  prospect  of  adhesion  being  procured,  or  sup- 
puration prevented.  We  are  then  chiefly  to  search  after, 
and  extract  foreign  bodies,  when  we  apprehend  that  their  re- 
moval may  permit  the  inflammation  to  be  resolved,  and  adhe- 
sion to  take  place,  and  when  we  expect  that  their  presence 
will  excite  a  greater  action  than  our  endeavours  to  extract 
them  will  do.  This  is  a  rule  which  ought  to  be  carefully  re- 
membered by  every  surgeon,  and  especially  by  those  whose 
situation  makes  them  be  daily  called  to  take  the  management, 
of  gunshot  wounds.  They  are  not  brought  to  their  patient 
to  show  how  much  they  can  do  in  the  way  of  cutting  and 
probing ;  it  is  their  duty  to  administer  relief,  and  act  so  as  to 
prevent  and  abate  the  inflammatory  action,  which  they  will 
often  do  most  effectually  by  letting  their  patient  alone,  and 
throwing  aside  their  ball-screws  and  forceps. 

The  circumstance  of  being  in  an  unusual  situation,  in 
which  the  natural  action  cannot  possibly  be  continued,  is  also 
a  very  frequent  cause,  producing  inflammation,  and  prevent- 
ing its  resolution.  We  ought,  upon  this  principle,  which  has 
been  formerly  mentioned,  to  endeavour,  in  almost  every  in- 
stance, to  bring  the  sides  of  the  wound  together,  if  a  wound 
has  been  the  exciting  cause  of  Inflammation,  by  which  we 
shall  much  more  readily  prevent  or  overcome  the  inflamma- 
tory action ;  because  we  thus  bring  the  parts  nearly  to  iheir 
natural  situation,  with  respect  to  interstice,  and  thus  make 
the  organic  particles  be  moie   readily   thrown  out.*     This 


*  Bringing  two  surfaces  in  contact,  although  theynaturally  werenot  so,  will  have: 
-ho  same  eflert1.    TmiP.ifUK1  sKri  be  faV?«n  off  'h^  pt»jcs  of  our  h'TTSrer5.  arid  fhe 


practice  ought  to  be  pushed  farther  than  is  often  done.  Even 
in  many  contused  wounds  it  will  be  useful ;  because,  although 
union  may  not  be  immediately  produced,  yet,  when  the  con- 
tused part  is  either  recovered,  or  absorbed,  the  inflammato- 
ry action  may  be  prevented,  or  removed,  by  the  restoration 
of  the  natural  action,  if  the  part  be  in  absolute  contact-  It 
must,  however,  be  remembered,  that  if  much  difficulty  be 
experienced  in  bringing  and  retaining  the  parts  together,  ow- 
ing to  the  swelling,  from  the  previous  existence  of  the  dis- 
eased action,  then  our  endeavour  will  be  hurtful ;  because 
the  irritation  which  we  thus  give,  has  a  greater  power  to  in- 
crease the  action,  than  the  circumstance  of  the  parts  being 
in  contact,  has  to  diminish  the  inflammation,  and  restore  the 
natural  action. 

By  removing,  then,  the  exciting  causes  of  inflammation, 
before  the  action  be  induced,  we  shall  frequently  prevent  it 
altogether  from  being  formed ;  but,  even  although  we  should 
be  disappointed,  we,  by  this  removal,  render  the  disease  mild- 
er, less  extensive",  and  much  more  easily  overcome  ;  for,  as 
long  as  the  exciting  causes  continue  to  operate,  it  is  impossi- 
ble to  procure  resolution  ;  but  the  action  will  be  kept  up  un- 
til some  other  termination,  or  consequence,  be  induced.  But, 
although  we  thus  prevent  the  action  from  being  raised  to  so 
great  a  degree  as  it  otherwise  would  be,  yet  we  do  not.  imme- 
diately overcome  or  destroy  it;  because  the  action,  when 
once  induced,  has,  like  every  other  action,  a  tendency  to 
continue  for  some  lime  after  its  cause  is  withdrawn.     This 


side  of  the  one  be  applied  to  the  side  of  the  other,  adhesion  will  take  place,  an<i 
no  inflammation  will  be  produced.  When  a  part  is  inflamed,  and  one  portion  is 
brought  in  contact  with  another,  we  uniformly  find,  that  the  inflammation  is  less 
■where  the  parts  were  in  contact  than  elsewhere.  Thus,  when  the  intestines  are 
inflamed,  the  parts  suffer  least  which  touch  other  intestines,  whilst  the  angle  be 
twixt  the  folds  is  most  affected.  This  fact  is  observed  by  Mr.  Hunter,  but  explain- 
ed upon  the  principle  of  contiguous  sympathy;  or,  "  a  mutual  harmony  being  pr<  - 
di.'rod,  which  prevents  their  being  inflamed." 


continuance  may  be  longer  or  shorter,  according  to  circura 
stances,  and  its  termination  may  be  more  or  less  unfavoura- 
ble. We  are,  therefore,  under  the  necessity  of  employing 
such  remedies  as  have  a  power  of  directly  diminishing  or  re- 
moving this  action.  It  has,  however,  been  doubted,  whether 
they  ought,  in  every  instance,  to  be  employed ;  or,  in  other 
words,  whether  resolution  ought  uniformly  to  be  desired.  It 
has,  for  instance,  been  deemed  unsafe  to  check  those  inflam- 
mations which  depended  upon  a  general  or  constitutional 
specific  disease,  or  occurred  during  its  existence.  But  this 
opinion,  which  was  evidently  founded  upon  the  supposition 
of  the  operation  of  morbid  humours,  cannot  be  maintained, 
now  that  this  is  given  up.  Granting  inflammation,  in  every 
one  of  these  cases,  to  be  dependent  upon  the  general  disease, 
and  to  exist  as  a  symptom  of  it,  no  harm  can  accrue  from  re- 
solving it  ;*  because,  if  the  inflammation  have  once  taken 
place,  the  full  effect  of  the  general  disease  is  produced, 
which,  therefore,  cannot  be  affected  by  the  peculiarity  of 
the  termination  of  this  inflammation,  unless  it  be  proved,  that 
some  humour  be  sent  there  to  be  concocted  and  thrown  out. 
In  many  instances,  inflammation  occurs  in  a  general  disease, 
merely  as  an  accidental  circumstance ;  but,  even  in  those, 
cases  where  the  local  inflammation  is  most  decidedly  depen- 
dent on  the  general  action,  and  is  perhaps  essential  to  it,  we 
find,  that  no  bad  effects  follow  from  resolving  the  inflamma- 
tion ;  and,  if  this  be  the  case  with  regard  to  specific  inflam- 
•jiation,  we  may  still  more  certainly  extend  the  principle  to 
the  treatment  of  the  simple  inflammatory  action,  with  which 
we  have  at  present  a  more  immediate  connexion.  There 
are,  however,  some  inflammatory  affections  which  we  some- 
times cannot  put  back;  such  as  those  tumors  which  succeed 


*  If  we  attempt,  without  fear,  to  cure  i lie  general  dhe.ise,  why  mi;'  ire  nfo* 
H\-r.  pr,^Pavo,,r  rn  (,attnr,  f^r.  tfTminatina  ^r         Ipcal  disease" 


8 

the  small-pox ;  but,  when  we  do  succeed,  no  bad  consequence 
follows  ;  and  the  failure  of  some  of  our  attempts  can  be  no  ar- 
gument against  the  general  plan,  more  than  our  failure  in 
many  other  instances. 

Resolution  is  the  quickest  termination  of  inflammation, 
and,  therefore,  ought,  perhaps  in  every  instance,  to  be  at- 
tempted, unless  in  cases  where  the  injury  is  such  that  suppu- 
ration is  unavoidable ;  as,  for  instance,  extensive  bruises,  &c. 
It  is  our  great  object,  even  in  those  inflammations  which  we 
raise  intentionally ;  as,  for  instance,  in  the  operation  for  hy- 
drocele. At  one  time,  however,  this  was  not  admitted  with- 
out limitation  ;  and  suppuration  was,  in  many  instances,  anx- 
iously sought  for,  being  considered  by  some  as  the  only  way 
of  obtaining  a  cure.  "  Union,  (says  Mr.  O'Halloran)  with- 
out suppuration,  by  an  immediate  coalescence,  or  by  the  first 
intention,  is  merely  chimerical,  and  is  opposite  to  the  rules 
of  nature.  Inflammation  (contrary  to  the  received  canon)  is 
not  the  time  for  a  re-union  of  divided  parts  :  This  happy 
minute  follows,  not  precedes  suppuration."  It  was  timidity, 
with  regard  to  the  prevention  of  suppuration,  and  want  of 
knowledge  of  the  powers  of  the  animal  frame,  which  so  long 
retarded  the  progress  of  surgery,  and  prevented  the  improve- 
ment of  its  operations. 

The  remedies  which  we  employ,  with  the  intention  of 
abating  and  removing  the  inflammatory  action,  are  either  ge- 
neral or  topical. 

General  remedies  are  perhaps  only  useful,  or  have  only  a 
superiority  over  topical  ones,  when  a  general  disease,  or  fe- 
ver, accompanies  the  local  inflammation.  Topical  ones  are 
only  to  he  trusted  to  alone,  when  the  disease  is  entirely  local. 
The  general  remedies,  are  naturally  such  as  tend  to  abate 
action  in  general,  or  to  diminish  the  natural  action ;  and  there 
fore,  will  consist  of  bleeding,  cold,  purging,  sweating,  nan 
seating  medicines,  and  some  of  the  agentes  dissimiles. 


9 

Bleeding  is  justly  considered  as  the  most  powerful,  and  the 
most  useful  of  all  those  remedies  ;  and,  in  many  cases,  is  the 
only  one  which  can  accomplish  a  cure.  The  quantity  of 
blood  which  it  is  necessary  to  detract,  will  be  regulated  by 
the  effect  of  the  inflammation  upon  the  system,  and  by  the 
previous  condition  of  the  person,  with  regard  to  strength  ;  for 
those  who  are  weak  bear  bleeding  worst ;  and  in  them  we 
cannot  repeat  it  so  frequently,  as  in  the  robust.  Delay  in 
them  is,  however,  more  dangerous ;  because  the  inflamma- 
tion makes  a  more  rapid  progress,  and,  therefore,  we  ought 
sooner  to  push  our  remedies. 

When  the  system  is  affected,  in  consequence  of  inflam- 
mation of  vital  parts,  the  general  action  is  greater  than  when 
other  parts  are  affected,  and,  therefore,  bleeding  must  be  used 
earlier,  and  with  more  freedom.  Mr.  Hunter  observes,  that 
when  these  parts  are  inflamed,  the  patient  bears  bleeding 
worse  than  when  parts  are  affected  which  are  not  vital :  but 
this  observation  must  not  be  admitted  indefinitely.  When 
these  parts  are  affected,  the  action  is  so  violent,  that  the 
power  cannot  long  support  it ;  and,  therefore,  we  must  have 
early  recourse  to  the  lancet,  and  allow  the  blood  to  flow  un- 
til the  pain  diminishes,  and  ceases  to  abate  any  more,  and  un- 
til the  pulse  becomes  softer,  and  perhaps  fuller.  This  is  the 
time  to  stop  ;  but,  whenever  the  pain  returns,  or  the  pulse 
becomes  hard,  the  orifice  should  be  again  opened,  although 
we  had  bled  only  half  an  hour  before.  The  system,  in  this 
way,  is  not  weakened,  nor  the  action  sunk  so  low  as  to  injure 
the  power  of  recovery,  which  might  be  the  case,  were  we 
to  bleed  too  copiously  at  once.  This  remark  applies,  in  a 
particular  degree,  to  inflamma.ion  of  the  bowels  ;  but  it  may 
also  be  extended  to  pulmonic  inflammation  ;  only,  in  this 
case,  we  can  detract  more  blood  at  a  time  than  in  the  other 
instance  ;  because  the  system  sympathises  less  strongly  with 
the  lungs,  and,  therefore,  general  evacuation  will  be  longer 


10 

of  operating  on  the  local  disease.  The  same  cause,  however, 
makes  the  danger  less  ;  because  the  general  action  is  not  rais- 
ed so  high,  and  the  part  itself  not  being  so  delicate,  can  sup- 
port the  action  longer,  and,  consequently,  the  danger  is  less. 
It  is  an  established  point,  that  no  action  can  subside,  or  be 
destroyed  suddenly,  and  the  patient  become  free  from  dis- 
ease. All  morbid  actions  must  subside,  more  or  less  slowly, 
and,  therefore,  bleeding  ought  not  at  once  to  be  pushed  so  far 
as  to  produce  fainting,  unless  the  patient  be  very  liable  to 
faint.  This  sudden  cessation  of  general  action  does  not  destroy 
the  specific  nature  of  the  action  which  is  going  on  when  it  is 
induced,  but  rather  leaves  the  parts  stationary,  the  tendency 
to  morbid  action  still  continuing,  although  the  capability  to 
act  be  suspended  for  a  moment.*  In  place,  then,  of  bleeding 
so  as  to  exhaust  the  strength  quickly,  and  endeavour,  as  it 
were,  by  the  quantity  of  the  discharge,  to  destroy  the  dis- 
ease by  one  bleeding,  it  will  be  much  better  to  bleed  just  un- 
til we  produce  the  feeling  of  weakness  to  a  moderate  extent, 
and  abate,  to  a  certain  degree,  the  pain  and  hardness  of  the 
pulse  ;  stopping,  whenever  we  find  that  we  are  not  abating  it 
farther,  distinguishing,  however,  betwixt  real  abatement  and 
syncope,  or  want  of  power  to  act  and  feel.  We  then  repeat 
the  evacuation,  whenever  the  hardness  of  the  pulse  and  pain 
return ;  and  thus,  perhaps  in  one  day,  and  with  infinitely 
more  benefit,  bleed  much  more  frequently,  and,  perhaps,  to 
a  greater  extent,  than  is  sometimes  done  in  a  week,  by  those 
who  bleed  more  copiously  at  once,  and  repeat  it  seldomer. 

Concerning  the  exact  quantity  of  blood,  which  ought,  in 
the  different  varieties  of  inflammation,  to  be  detracted,  I  hold 
it,  from  the  above  principle,  to  be  ridiculous  to  give  any  di- 


*  When  we  are  obliged  to  stop  our  bleeding,  on  account  of  fainting,  before  wr- 
would  otherwise  do  it,  we  will  find  it  necessary  to  repeat  the  venesection  soonti 
than  if  this  did  not  happen. 


11 

rection ;  because  no  general  rule  can  be  given,  by  which  we 
may,  a  priori,  determine  the  quantity.  We  are  to  bleed 
until  we  procure  an  abatement  of  the  action  ;  and  to  stop 
whenever  this  abatement  ceases  to  be  really  progressive.* 
We  are  to  renew  the  bleeding,  whenever  the  action  again  in- 
creases, and  stop,  as  before,  whenever  it  is  abated,  remem- 
bering, that,  after  some  time,  a  more  sparing  detraction  will 
produce  a  greater  effect,  than  a  more  copious  one  would  do, 
in  the  commencement  of  the  disease.  It  must  also  be  at- 
tended to,  that,  owing  to  the  weakness  induced  by  the  dis- 
ease, and  by  the  bleedings,  we  must,  toward  the  end,  bleed  at 
longer  intervals  ;  for,  if  we  continue  to  bleed  in  the  same 
way  as  formerly,  we  would  either  kill  the  patient,  or  at  least 
prevent  the  act  of  restoration  from  taking  place  ;  because  we 
would  thus  diminish  the  power,  or  vital  energy,  which  was  to 
perform  this  act.  Those,  then,  who  order  a  certain  number 
of  ounces  to  be  taken  away,  must  reason  upon  probability, 
and  prescribe  less  efficaciously,  than  those  who  direct  no  der 
terminate  quantity,  but  regulate  their  practice  by  the  effects. 
It  is  equally  foolish  in  those  who  order  bleeding,  pro  viribus? 
and  are  satisfied  with  this  until  their  next  stated  visit ;  be- 
cause bleeding  until  fainting  takes  place,  and  not  repeating  it 
for  some  time  afterwards,  may  be  doing  a  great  deal  too 
little. 

As  there  is  a  proper  time»for  stopping  each  individual  eva- 
cuation, so  also  is  there  a  period  at  which  we  ought  to  stop 
the  general  plan  of  cure  by  bleeding,  or  at  least  to  intermit  it. 
And  to  determine  when  this  period  is  come,  is  sometimes  a 
pretty  nice  point,  and  one  of  much  importance  ;  because,  if 
we  stop  too  soon,  we  allow  the  action  still  to  go  on,  and,  per- 


*  We  must  distinguish,  as  has  been  already  mentioned,  betwixt  a  real  abatement 
of  the  inflammatory  action,  and  a  mere  temporary  suspension  of  action,  or  syh 
cope. 

ror,.  li.  « 


12 

haps,  to  terminate  fatally.  On  the  other  hand,  if  we  bleed 
too  long,  we  sink  the  parts  below  the  state  necessary  for  re- 
covery, and  even  accelerate  the  unfavourable  termination. 
When,  for  instance,  from  the  state  of  the  pulse,  and  other 
circumstances,  we  apprehend  the  accession  of  gangrene, 
bleeding  will  not  abate  pain,  but  will  bring  on  the  mortifica- 
tion sooner,  and  make  it  spread  farther,  as  will  be  afterward? 
mentioned. 

As  the  accession  of  inflammation  depends  upon  a  change 
of  the  natural  action  of  the  vital  principle,  so  does  its  re- 
moval depend  upon  the  reconversion  of  this  into  the  natural 
action,  which  implies  activity,  or  an  active  state.  If,  then, 
we  bleed  in  the  end  of  inflammation,  we  lessen  the  powers  of 
the  part  so  much,  as  to  prevent  restoration ;  gangrene,  there- 
fore, will  take  place  :  Or,  if  the  part  be  less  delicate,  and  the 
progress  of  the  action  consequently  slower,  the  inflammation 
may  continue  stationary  for  a  considerable  time,  and  become 
chronic,  or  habitual.  This  state  is  not  to  be  cured  by  bleed- 
ing, but  will  rather  be  made  worse  by  it.  AVhenever,  then, 
after  inflammation  has  continued  for  a  length  of  time,  we  find, 
that  venesection  does  not  produce  the  usual  abatement  ;  or, 
whenever,  although  there  be  a  temporary  abatement,  the 
pain  increases  afterwards  to  a  greater  degree,  we  may  be 
certain  our  treatment  is  improper.  We  likewise  find,  thai 
the  longer  bleeding  has  been  delayed,  in  the  beginning  of 
the  disease,  the  sooner  must  we  stop,  and  the  less  quantity 
must  we  take  at  a  time  ;  because,  in  this  case,  the  inflamma- 
tory action  is  nearer  its  termination,  and  is  more  ready  to 
produce  gangrene,  if  the  parts  be  delicate,  or  the  action 
great,  or,  if  otherwise,  the  inflammatio  assuefacta.  We  are 
also  to  refrain  from  bleeding,  when  we  find  that  the  inflam- 
matory action  is  about  to  terminate  in  another  action  ;  as, 
for  instance,  the  suppurative  ;  because,  in  the  first  place, 
Weeding,  in  this  new  action,  can  do  no  good,  but,  by  weaken- 


13 

tng,  will  do  harm ;  and,  secondly,  if  there  be  only  a  tenden- 
cy to  this  action,  the  action  not  being  yet  formed,  or  be- 
ginning to  form,  we  may,  by  bleeding,  interrupt  the  progress 
of  the  inflammation,  and  convert  it  into  a  more  tedious  dis- 
ease, or  the  inflammatio  assuefacta. 

Bleeding  has  been  used,  not  only  as  a  cure  for  inflamma- 
tion, but  also  as  a  preventive ;  but  this  must  be  consider- 
ed as  proper,  only  in  particular  instances.  When,  for  in- 
stance, a  wound  has  been  inflicted,  or  an  operation  necessa- 
rily performed,  on  a  robust  person,  bleeding  immediately,  or 
very  soon  after  it,  may  be  useful;  because  it  will  tend  to 
lessen  the  chance  of  the  natural  action  being  carried  so  high 
as  to  become  changed.  These  people  cannot  have  their  ac- 
tion much  increased  without  disease;  and,  therefore,  it  is 
necessary  to  lessen  it,  and  bring  it  down  to  a  more  proper 
medium.  But  there  are  other  cases,  where  the  action  is  na- 
turally rather  too  low,  and  the  patient  weakly.  In  these 
cases,  bleeding  can  do  no  good,  but  much  harm  ;  because  it 
increases  the  previous  weakness,  and  makes  the  inflamma- 
tion, if  it  does  occur,  more  dangerous,  on  account  of  the 
little  power  which  there  is  to  support  the  action.  These 
people  even  bear  bleeding  worse  than  others,  when  inflam- 
mation has  actually  taken  place.  It  ought  never  to  be  prac^ 
tised,  in  order  to  reduce  the  natural  action,  before  disease 
has  taken  place ;  and,  after  the  inflammatory  action  is  in- 
duced, it  ought  to  be  used  cautiously,  and  only  to  such  an 
extent,  as  may  be  necessary  for  removing  the  tendency  to 
immediate  bad  consequences.  It  ought,  however,  to  be  used 
very  early  in  the  disease ;  because,  in  weak  people,  the  ac- 
tion does  more  harm  in  a  given  time,  than  in  the  strong  ; 
but  it  ought  likewise  to  be  sooner  abandoned,  otherwise  we 
either  hasten  morliGration,  or  prevent  the  act  of  restoration 
from  taking  place, 


14 

Bleeding  is  rarely  necessary  in  inflammation  of  the  cellu- 
lar  substance  alone,  unless  the  action  be  extensive  ;  in  which 
case,  the  system  is  so  affected,  as  to  require  our  inter- 
ference. When  the  cutis  is  inflamed,  producing  erysipelas, 
the  system  suffers  considerably ;  but,  as  this  frequently  ends 
in  mortification,  bleeding  has  been  neglected  by  many  ;  but 
it  is  evident,  that,  if  the  disease  be  simple,  and  not  depend- 
ent upon  any  specific  agens  dissimilis,  or  epidemic  conta- 
gion, venesection  is  the  proper  cure,  provided  it  be  early 
employed,  as  we  thus  diminish  the  action  more  certainly 
than  by  any  other  means.  If,  however,  the  disease  have 
been  neglected,  and  the  action  be  nearer  a  termination,  then 
we  must  either  do  nothing  in  the  way  of  general  treatment, 
or  must  give  opposite  remedies  from  bleeding,  according  to 
circumstances.  When  muscles  are  inflamed,  bleeding  is 
often  necessary  to  a  very  great  extent,  as  we  observe  in 
rheumatism  ;  and,  in  the  beginning,  we  must  take  a  greater 
quantity  at  a  time,  in  order  to  procure  an  abatement,  than 
in  many  other  cases.  When  the  viscera  are  inflamed, 
bleeding  is  uniformly  necessary,  and  generally  requires  to 
be  frequently  repeated. 

It  is  a  common  opinion,  that  the  blood  ought  to  be  taken, 
if  possible,  from  a  vein  which  arises  from,  or  near  the  affect- 
ed part ;  that,  for  instance,  in  phrenites,  we  should  bleed  hi 
the  jugular  vein ;  in  inflammation  of  the  feet,  we  should  bleed 
in  the  leg,  &c.  And,  when  this  can  conveniently  be  done,  it 
may  be  preferred ;  because,  it  not  only  possesses  all  the  ad- 
vantages of  general  bleeding  from  any  other  vein,  but  also 
may  be  supposed  to  produce,  in  a  slight  degree,  a  topical 
evacuation.  If,  however,  the  veins  be  so  small,  that  we  can- 
not detract  enough  of  blood,  and  sufficiently  quick ;  or  if, 
from  any  other  cause,  we  cannot  do  so,  then,  if  the  general 
action  be  violent,  we  must  have  recourse  to  another  vein,  as 
$be  Ipss  to  be  sustained,  by  confining  ourselves  to  this  vein, 


15 

is  infinitely,  greater,  than  any  good  which  can  be  derived 
from  it,  as  a  local  evacuation.  Indeed,  when  we  consider 
the  laws  of  the  circulation,  we  must  allow,  that  very  little 
good  can  be  done  in  this  way,  as  a  local  detraction ;  because 
one  vein  does  not  lose  more  blood  than  another,  except  dur- 
ing the  moment  of  the  flow. 

The  blood,  when  drawn  during  inflammation,  has  always  a 
buffy  coat,  which  is,  in  general,  thicker,  and  more  concave, 
in  proportion  to  the  violence  of  the  inflammatory  action ; 
and  the  continuance  of  this  condition,  is  one  circumstance 
which  points  out  the  necessity  of  continuing  our  evacuation  : 
But  the  mere  existence  of  a  buffy  crust,  is  not,  without  these 
circumstances,  any  infallible  sign  of  the  necessity  of  bleed- 
ing; because  this  crust  is  to  be  found  on  the  blood,  after  the 
inflammation  has  begun  to  become  passive ;  and  it  is  to  be 
found  also,  when  mortification  is  approaching;  we  observe  it 
likewise  very  frequently  upon  the  last  cup  of  blood  which 
we  find  it  necessary  to  take  away.  In  these  cases,  however, 
the  crust  is  much  softer,  generally  thinner,  always  flat,  in- 
stead of  concave,  and  looser  in  the  texture  ;  it  is  also  more 
of  a  greenish  hue.  These  circumstances,  conjoined  with  the 
state  of  the  pulse,  will  enable  us  to  judge,  whether  we  should 
totally  desist  from,  or  continue  our  evacuations  with  caution. 
Most  frequently  they  forbid  farther  bleeding. 

Cold,  or  the  subduction  of  heat,  is  chiefly  useful  as  a  topi- 
cal application;  but  it  is  also  proper  to  be  applied,  in  mode- 
ration, for  the  abatement  of  the  general  fever,  unless  we  be 
desirous  of  procuring  perspiration.  The  quantity  of  bed- 
clothes ought  to  be  lessened,  cold  drink  should  be  allowed, 
and  a  free  circulation  of  cool  air  into  the  room.  The  appli- 
cation of  cold,  however,  ought,  in  general,  only  to  be  carried 
to  such  an  extent  as  shall  be  sufficient  for  diminishing  the 
morbid  degree  of  heat,  and  not  so  far  as  to  produce  sensible 
♦jold,  or  the  sensation  of  cold  ;  because  this,  in  many  instan- 


16 

ces,  will  be  pernicious,  upon  the  principle  of  the  sympathy 
of  equilibrium,  the  action  of  the  internal  parts  being  increas- 
ed by  the  speedy  application  of  cold  to  the  surface  ;  and, 
therefore,  if  the  internal  parts  be  inflamed,  their  morbid  ac- 
tion must  be  still  farther  increased.  If  the  cold  be  long  ap- 
plied, to  any  considerable  degree,  it  will  likewise,  by  the 
sympathy  of  association,  weaken  the  whole  system  too  much, 
and  injure  the  act  of  restoration.  As  bleeding  is  to  be  used 
only  until  it  restores  a  natural  state,  and  abates  pain,  so  also 
is  cold  only  to  be  applied  in  such  a  degree  as  may  be  neces- 
sary for  diminishing  the  preternatural  heat,  and  sensation  of 
the  surface ;  which  it  does,  by  lessening  the  morbidly  in- 
creased action,  and  reducing  it  to  the  natural  state.  The 
degree  must  therefore  gradually  be  diminished,  in  proportion 
as  the  general  disease  subsides,  otherwise  we  injure  the  sys- 
tem, and  prevent  recovery.  There  is,  however,  this  differ- 
ence betwixt  bleeding  and  the  application  of  cold,  that  the 
first  may  be  used  suddenly,  and  to  a  considerable  extent  at 
once,  whereas,  the  second  ought,  especially  in  all  cases  of 
internal  inflammation,  to  be  employed  more  slowly,  and  its 
degree  regulated  by  the  degree  of  the  general  heat  of  the 
surface. 

Nauseating  medicines  are  also  very  useful,  independently 
of  the  sweating  which  they  frequently  induce ;  and  are  a 
very  powerful  mean  of  abating  action  in  general.*  Employ- 
ed, after  bleeding  has  been  used  once  or  twice,  they  are  pro- 
ductive of  considerable  benefit ;  but  there  are  some  affec- 
tions, in  which  they  cannot  be  used,  such  as  inflammation  of 
the  stomach  and  intestines  ;  but  in  inflammation  of  the  lungs, 
•f  the  throat,  muscles,  or  surface,  they  may  often  be  pre 
scribed  with  benefit.  The  remedies  usually  employed  for 
this  purpose,  are,  small  doses  of  emetics,  given  without  drink. 

*  Nausea  has  often  been  employed  with  success,  in  checking  active  hemorrhage, 


17 

It  must,  however,  be  remembered,  that  these  frequently 
produce  considerable  evacuations,  either  from  the  skin  or 
bowels,  and,  therefore,  may  occasion  a  permanent  weakness. 
We  must  likewise  avoid  raising  the  sickness  to  a  great  de- 
cree, and  keeping  it  long  up ;  because  the  same  objection 
applies  nearly  to  this  as  to  bleeding  ad  deliquium. 

Purging  is  frequently  employed  in  the  cure  of  inflamma- 
tion, especially  such  purgatives  as  are  called  cooling,  which, 
in  this  case,  is  an  imaginary  quality;  but,  unless  in  so  far  as 
they  tend  to  abate  the  irritation  of  costiveness,  they  can  do 
no  more  than  bleeding  can,  and  are,  in  many  respects,  infe1- 
rior  to  it.  They  are,  in  one  view,  to  be  compared  with  the 
application  of  cold,  which  is  only  indicated  when  there  is 
much  heat ;  both  are  intended  to  diminish  action,  chiefly  by 
removing  stimuli  from  the  part  to  which  they  are  applied. 
Purging  is  very  uncertain  in  the  effects  which  it  produces 
on  the  system,  and  in  the  degree  of  weakness  which  it  cau- 
ses; and,  therefore,  never  can  be  put  in  competition  with 
bleeding,  as  a  general  remedy  ;  and,  wherever  bleeding  is 
improper,  or  its  propriety  doubtful,  purgatives  are  still  more 
injurious.  They  operate  likewise  so  slowiy,  at  least  com- 
paratively speaking,  that  they  do  not  influence  the  local  ac- 
tion so  much,  as  the  loss  of  such  a  quantity  of  blood,  as  would 
produce  an  equal  effect  on  the  body,  will  do,  unless  in  parti- 
cular cases,  when  they  act  upon  the  principle  of  the  sympa- 
thy of  equilibrium  ;  as,  for  instance,  in  pulmonic  inflamma- 
tion, when  they  sometimes  are  of  service,  by  increasing  the 
action  of  the  intestines,  and  diminishing  that  o:'  the  lungs.* 
fn  the  same  way,  emetics  sometimes  cure  slight  inflamma- 
tion of  the  tonsils.  One  of  the  best  and  pleasantest  saline 
purgatives,  is  the  phosphate  of  soda,  which  may  be  given  to 
an  adult  in  the  dose  of  an  ounce,  in  order  to  obviate  the  ef- 

■  Thi-  action  is,  in  tMh  respect;  similar  to  that  of  Milters, 


18 

fects  of  costiveness.  If  we  wish  to  use  it,  upon  the  princi- 
ple of  the  sympathy  of  equilibrium,  we  must  give  two  ouni^es, 
or  more.  The  same  cautions  which  were  given,  with  regard 
to  bleeding,  apply  also  to  purging. 

Sweating,  considered  as  a  mean  of  abating  general  action, 
is,  in  most  cases,  inferior  to  bleeding  ;  and  can  never,  when 
the  general  inflammatory  action  is  considerable,  be  trusted 
to  alone ;  but,  after  the  use  of  the  lancet,  it  is  generally 
serviceable.  It  is  useful,  in  particular,  when  the  local  dis- 
ease is  not  confined  to  a  small  spot,  but  affects  a  considera- 
ble surface,  or  different  parts  of  the  body  ;  as,  for  instance, 
in  the  rheumatism  ;  but  it  acts,  in  these  cases,  rather  by  the 
sympathy  of  equilibrium,  than  by  any  other  mode.  At  the 
same  time,  the  induction  of  a  sweat,  preceded  by  Weeding, 
(which  tends  to  abate  the  local  action  as  well  as  the  general 
one)  will  sometimes  be  useful,  by  giving  a  secretory  termina- 
tion to  the  general  disease,  and  hastening  its  conclusion.  In 
the  first  point  of  view,  sweating  may  be  used  early  in  the 
disease,  especially  if  preceded  by  bleeding.  In  the  second, 
it  will  be  chiefly  useful  toward  the  end,  as  it  will  then  ac- 
celerate the  termination,  and  thus  influence  the  local  action  ; 
for  the  abatement  of  the  general  action  must  also  produce 
an  abatement  of  the  action  of  a  particular  part.  Sweating, 
as  well  as  purging,  must  be  used  with  caution  in  weakly  peo- 
ple, or  in  those  who  are  reduced  by  disease ;  because,  al- 
though the  action  of  particular  parts  may  be  increased  by 
it,  yet,  partly  in  consequence  of  this  temporary  increase, 
and  partly  on  account  of  the  fluid  which  is  discharged,  gene- 
ral weakness  is  induced.  One  of  the  best  sudorifics  is  the 
pulvis  ipecacuanha  comp. ;  of  which  we  may  give  ten  grains 
every  hour,  until  sweating  be  produced,  giving  warm  lemon- 
ade along  with  it.     The  tartar  emetic  is  also  a  very  useful 


sudorific  ;  the  sixth  part  of  a  grain  may  be  given  every  half 
hour,  until  the  proper  effect  be  produced.* 

Some  of  the  agentes  dissimiles  may  be  considered  as  pro- 
per remedies  in  this  complaint ;  such  as,  digitalis,  laurel  wa- 
ter, lead,  &c.  :  But  they  are  certainly  inferior  to  blood-let- 
ting; and  have  been  so  little  employed  in  this  way,  that 
their  effects  are  not  ascertained.f 

Bleeding,  of  all  the  general  remedies,  is  the  best ;  and, 
next  to  that,  cold,  and  nausea,  which  may  be  considered  as 
useful  adjuvants.     Sweating  and  purging  are  mostly  to  be 
used  when  particular  indications  present  themselves,  as  may 
be  understood  from  what  has  been  already  said.     The  first 
of  these  remedies,    act    chiefly  by  producing  a  universal 
abatement  of  action  ;  and,  of  these,  bleeding  produces  the 
most  permanent  effect  on  the  body,  and  the  most  certain  ef- 
fect on  the  local  disease.     The  two  last  are  perhaps  more 
useful,  upon  the  principle  of  the  sympathy  of  equilibrium, 
than  that  of  abating  action  in  general,  which  is  only  a  se- 
condary operation  ;  and,  therefore,  they  may  be  considered 
as  remedies,  acting  rather  topically  than  generally  ;  for,  ac- 
cording to  this  view,  they  act  chiefly  on  the  affected  part. 
These  two  kinds  of  remedies  may,  in  many  cases,  be  use- 
fully conjoined,  producing  thus  a  greater  effect  than  either 
would  do  singly. 

Before  quitting  this  subject,  it  may  not  be  improper  to  at- 
tend to  the  proposal  which  has  been  made,  of  exhibiting 
anodynes  immediately  after  bleeding,  in  order  to  remove  the 
pain.  "  The  most  effectual  remedy  for  this  purpose,  (says 
Mr.  Bell)  is  opium,  which,  when  pain  and  irritation  are  con- 


*  One  grain  of  emetic  tartar  may  be  dissolved  in  five  ounces  of  saline  julep,  and 
a  table  spoonful  given  every  half  hour,  as  long  as  may  be  necessary. 

f  Some  of  these  agents  might  perhaps  only  change  the  nature  of  the  inflamma- 
tion, and  render  it  specific? 

VOL.    II.  t 


20 

siderable,  as  in  extensive  inflammations  very  frequently  hap- 
pens, should  never  be  omitted.  In  large  wounds,  especially 
after  amputations,  and  other  capital  operations,  in  punctures 
of  all  kinds  too,  large  doses  of  opium  are  always  attended 
with  remarkably  good  effects.  In  all  such  cases,  however, 
opium,  in  order  to  have  a  proper  influence,  should,  as  we 
have  observed,  be  administered  in  full  doses,  otherwise,  in- 
stead of  proving  serviceable,  it  seems  rather  to  have  the 
contrary  effect ;  a  circumstance  which  is  perhaps  the  chief 
reason  why  opiates  in  general  have  been  very  unjustly  con- 
demned, in  every  case  of  inflammation."  That,  in  every 
case  of  inflammation,  opiates  are  hurtful,  is  what  no  one  can 
assert ;  and  their  utility  will  afterwards  be  fully  manifested. 
But,  that  opium  is  useful,  or  even  harmless,  in  the  inflamma- 
tio  valida,  which  we  are  at  present  considering,  cannot  be 
admitted  ;  because  daily  experience,  independent  of  every 
theory,  proves,  that,  by  their  use,  the  general  fever  is  in- 
creased, and  the  local  action  aggravated.  Even  given  as  a 
preventive  of  inflammation,  after  operations,  anodynes  are 
almost  uniformly  hurtful,*  producing  restlessness,  heat,  and 
thirst,  and  afterwards  head-ache,  sickness,  and  frequently 
troublesome  vomiting.  I  have  therefore  now,  after  almost 
every  operation,  laid  aside  their  use,  and  find,  that  the  dis- 
eased action,f  subsequent  to  the  local  irritation,  runs  its 
progress  with  much  less  disturbance,  and  is  much  milder, 


*  Opiates  may  indeed  abate  the  smarting,  or  soreness,  which  is  consequent  to 
the  immediate  mechanical  injury  of  wounds,  or  operations  ;  but  this  relief  is  com 
monly  only  temporary ;  for  the  general  action  is  very  apt  to  be  afterwards  in- 
creased, and,  consequently,  union  by  adhesion  is  less  likely  to  take  place. 

f  There  are  two  general  diseases  which  are  connected  with  local  actions,  and 
which  opium  is  supposed  to  cure,  or  prevent  from  taking  place;  the  inflammatory 
fever,  dependent  on  a  wound,  and  the  febrile  state,  consequent  to  a  temporary  in- 
creased action,  or  exertion  of  a  particular  part,  or  the  whole  of  the  system  ;  as, 
for  instance,  the  effect  of  part uritior..  The  first  of  these  is  always  aggravated  by 
opium;  the  second,  if  It  be  not  increased,  cannot  possibly  be  cured  by  it. 


21 

and  shorter,  than  where  anodynes  have  been  administered ; 
and,  in  general,  the  sleep  is  much  more  composed,  and  al- 
ways more  refreshing.  I  have  therefore,  after  lithotomy, 
amputation,  the  extirpation  of  the  mammae,  and  after  labours, 
in  almost  every  instance,  omitted  them. 

The  local  applications  are  such  as  tend  either  simply  to 
abate  action  in  the  part,  or  such  as  tend  to  change  its  na- 
ture, by  exciting  a  specific  change,  or  such  as  act  in  both 
ways.  The  first  comprehends  cold,  the  second  the  agentes 
dissimiles,  and  the  third  topical  bleeding. 

Cold,  applied  directly  to  the  inflamed  part,  is  a  most  use- 
ful remedy,  diminishing  the  action  to  a  natural  state  ;  but, 
for  this  purpose,  it  must  not  be  applied  in  too  great  a  degree, 
otherwise  we  diminish  the  action  so  much,  and  so  suddenly, 
(and,  consequently,  the  power  of  the  part)   that  recovery 
cannot  take  place.     If  we  apply  much  cold  to  a  healthy 
part,  we  sink  its  action  so  far,  that  it  is  irrecoverable  ;  if 
we  apply  cold  to  an  inflamed  part,  so  as  to  diminish  its  ac- 
tion equally  sudden,  and  in  the  same  proportion,  we  pro- 
duce the  same  effect.     Poultices  of  ice,  or  snow,  are  there- 
fore highly  dangerous  ;  and  even  water,  although  it  cannot 
be  made  nearly  so  cold  as  these.     The  same  direction  which 
has  been  given,  with  regard  to  the  application  of  cold  as  a 
general  remedy,  ought  also  to  be  remembered,  when  we  use 
it  as  a  local  application,  namely,  it  ought  to  be  carried  just 
to  such  a  degree,  as  shall  diminish  the  morbid  sensation,  and 
ought  to  be  so  adjusted,  as  to  keep  the  part  nearly  in  its  na- 
tural degree,  or  at  least  very  little  lower.     For  this  purpose, 
it  must  be  applied  in  moderation,  repeatedly,  and  with  assi- 
duity ;  and  not,  as  is  commonly  done,  in  a  considerable  de- 
gree at  once,  and  renewed  only  at.  long  intervals.     Cold  has 
been  supposed  to  be  useful  as  an  active  astringent,  producing 
a  contraction  in  the  vessels  ;  but  it  does  not  seem  to  possess 
any  active  power  in  producing  such  a  state  in  the  vessels  to 


22 

which  it  is  applied.     Where  injury  is  taking  place,  from  ex- 
cessive action,  cold,  by  abating  it,  may  strengthen,  and  pro- 
duce   more  natural    contractions ;   but,  when  applied  to  a 
healthy  part,  it  diminishes  the  action  of  that  part,  the  blood 
is  less  forcibly  circulated,  and  the  part  shrinks  ;  it  therefore 
stops  active  hemorrhage  in  the  part  on  which  it  acts.     When 
cold  is  applied  suddenly,  or  to  delicate  parts,  it  excites  an 
universal  action,  or  contraction,  or  shrinking,  from  weakness  ; 
and,  therefore  may  likewise  stop  hemorrhage  from  distant 
parts.     In  many  cases,  when  this  shrinking,  or  temporary 
contraction,  is  suddenly  induced  by  cold,  it  becomes  con- 
verted into  the  natural  muscular  contraction  of  the  part ; 
thus,  for  instance,  if  cold  be  applied   to  the  uterus  itself,* 
when  torpid,  after  delivery,  we  find,  that  after  the  first  ef- 
fect, or  shrinking  of  the  vessels,  a  more  natural  contraction 
takes  place.     If,  however,  cold  be  long  applied,  we  find,  that 
the  contraction  thus  induced  ceases,  owing  to  the  diminution 
of  action  which  is  occasioned  by  its  continuance,  and  the 
original  state  of  collapse,  or  shrinking,  alone  remains. 

Blisters  likewise  act  by  simply  abating  the  action  of  the 
part ;  but  differ  from  cold,  in  requiring  to  be  applied,  not  to 
the  part  which  is  affected,  but  to  some  other,  with  which  it. 
exhibits  the  sympathy  of  equilibrium  ;  as,  for  instance,  to 
the  integuments  of  the  thorax,  in  pulmonic  inflammation  ;  to 
the  skin  of  the  knee,  in  affections  of  the  joint,  &c.  It  is, 
however,  necessary,  when  a  general  disease,  or  fever,  is  in- 
duced, that  bleeding  be  fully  employed,  before  we  have  re- 
course to  blistering  ;  because,  if  it  be  not,  the  inflammation 
excited  by  the  blister,  co-operates  to  increase  the  fever, 
along  with  the  original  disease,  which  it  has  not  had  time  to 
overcome,  or  lessen.     Blistering  likewise  acts  more  effect  u- 


*  When  applied  to  the  skin  of  the  abdomen,  it  acts  chiefly  by  exciting  action. 
on  the  principle  of  the  sympathy  of  equilibrium. 


23 

ally,  when  the  local  action  has  been  already  diminished,  by 
previous  bleeding.  The  size  of  the  blister  should  be  pro- 
portioned to  the  probable  extent  of  the  diseased  action  ;  a) 
the  same  time,  we  must  set  bounds  to  this  magnitude  ;  be- 
cause, if  loo  large,  they  may  not  only  produce,  or  keep  up  a 
general  disease,  but  also,  by  lessening  the  action  of  the  in- 
ternal parts  too  much,  and  too  quickly,  they  may  prevent 
recovery.*  It  is  therefore  better  to  apply  them  of  a  mo- 
derate size,  and  renew  them  frequently,  than  to  apply  one 
too  large  at  once.  It  must,  however,  be  remembered,  that 
inflammations  of  every  part  are  not  equally  readily  over- 
come in  this  way  ;  and,  therefore,  one  will  require  a  larger 
blister  than  another  ;  thus,  the  same  quantity  of  inflamma- 
tory action  in  the  brain,  will  be  more  difficultly  subdued, 
than  in  the  breast ;  and,  therefore,  we  must  apply,  in  that 
case,  a  larger  blister.  As  it  is  the  inflammatory  action,  in- 
duced by  the  blister,  and  not  the  discharge,  as  was  once  sup- 
posed, which  is  useful,  it  follows,  that  the  same  blistered 
place  should  not  be  kept  too  long  from  healing,  or  in  the  stale 
of  an  issue,  but  that  we  ought  rather  to  apply  a  succession 
of  blisters  ;  and  this  succession  should  be  pretty  rapid. 
There  is  indeed  one  case,  in  which  issues  are  admissible, 
namely,  where,  from  the  nature  of  the  inflamed  part,  or  the 
peculiarity  of  the  inflammation,  if  it  he  specific,  or  scrophu- 
lous,  the  progress  of  the  action  is  very  slow.  In  these  cases, 
a  rapid,  and  continued  succession  of  blister  would,  doubtless, 
be  most  useful,  but,  from  the  duration  of  the  treatment, 
would  scarcely  be  submitted  to :  Issues,  which  are  'ess  pain- 
ful, and  less  troublesome,  are,  therefore,  generally  preferred. 
We  have  an  instance  of  this  in  many  diseased  joints. 


Were  this  not  the  case,  we  should  enre  pulmonic  inflammation,  with  tin 
greatest  certainty,  by  covering  the  n-hoh  thorax  with  a  blister. 


24 

The  remedies  which  tend  to  diminish  the  inflammatory 
action,  by  producing  a  peculiar,  or  specific  change,  are,  the 
agentes  dissimiles,  of  which,  for   this  purpose,  lead  is  the 
best,  and  the  one  which  is  most  frequently  employed.  Lead, 
in  the  state  of  an  oxyde,  was  long  ago  used  ;  but  it  does  not 
appear,  in  this  condition,  to  have  much  activity ;  and,  there- 
fore, the  saline  preparations  are  now  introduced  into  use. 
The  acetite  of  lead,  on  account  of  the  supposed  power  of 
vegetable  acids  in  abating  inflammation,  has  been  considered 
as  possessing  a  great  superiority  over  other  forms ;  but  its 
chief  recommendation  over  other  soluble  preparations,  is  its 
cheapness  ;  for  the  nitrate  of  lead  seems  to  be  equally  pow- 
erful.    The  acetite  of  lead  may  be  employed,  either  before 
or  after  crystallisation ;  but,  if  we  use  the  crystals,  they 
must  be  redissolved;  for  which  purpose,  soft,  or  distilled 
water,  must  be  employed,  otherwise  a  decomposition  takes 
place.     The  strength  of  the  solution  which  we  apply,  must 
be  determined  by  the  natural  delicacy  of  the  part,  and  its 
morbid  sensibility,  in  consequence  of  inflammation.     In  the 
inflammatio  valida,  in  which  alone  it  is  proper,  the  solution 
never  ought  to  be  so  strong  as  to  produce  pain.     When  the 
eye,  urethra,  and  other  delicate  parts,  are  inflamed,  the  ap- 
plication ought  to  be  just  so  strong  as  to  produce  sensation, 
and  should  be  very  frequently  repeated.     When  the  cellu- 
lar substunce  is  inflamed,  and  we  begin  the  application  before 
tins  cutis  be  much  affected,  the  solution  will  not  require  to 
be  so  strong  as  to  produce  sensation ;  because,  were  it  to  be 
so,  the  action  excited  might,  from  the  quantity  required  to 
Produce  the  effect,  be  so  great,  and  so  suddenly  induced, 
that  the  powers  of  recovery  would  be  lost,  or  a  specific  in- 
flammation be  occasioned,  as  we  observe,  when  the  solution 
is  very  much  concentrated,  in  which  case,  even  sloughs  are 
sometimes  produced.     On  the  same  account,  we  must  renew 
the  application  frequently,  at  least  if  we  use  pledgets,  other- 


25 

wise  the  evaporation  of  the  solvent  increases  the  strength 
more  than  we  desire.  For  incipient  phlegmon,  we  may  em- 
ploy a  solution  consisting  of  three  pounds  of  rain  or  river 
water,  and  five  drachms  of  sugar  of  lead  ;  or  the  following, 
which  is  more  elegant  : 

R.  Cerussa  Acetatae  dr.  iii  ss. 

Aceti  Vini  unc.  iii.  Solve  super  focum  dein  adde. 
Aq.  Distill.  Frigid,  lb.  i  ss. 
Aq.  Rosar.  unc.  iv. 

This  may  be  applied  by  means  of  pledgets  of  linen  ;  or  part 
of  it  may  be  made  into  a  poultice,  with  crum  of  stale  bread. 

Saturnine  poultices  ought  always  to  be  applied  cold ;  be- 
cause we  thus  receive  both  the  benefit  of  the  cold,  and  of 
the  lead.  The  directions  which  have  already  been  given, 
with  regard  to  the  application  of  cold,  are  to  be  attended  to- 
here. 

Lead  has  been  supposed  to  act  as  an  astringent ;  but,  if 
astringents  were  useful,  alum  would  be  more  effectual  than 
any  of  the  preparations  of  lead. 

The  vegetable  acids  have  been  considered  as  sedatives, 
and  are  generally  employed  in  the  cure  of  inflammation  •,  but 
it  would  rather  seem,  as  if  they  belonged  to  the  class  of 
agentes  similes ;  for,  in  moderate  quantities,  they  increase 
the  appetite,  &c.  which  no  sedative,  or  agens  dissimilis,  ever^ 
does  :*  They  also  excite  a  general  action,  which  is  different 
from  that  induced  by  sedatives,  and  which  is  useful  in  cur- 
ing many  of  the  actions  induced  by  these  agents.  We  like 
wise  find,  that  they  are  not  serviceable,  as  local  applications, 


*  Like  other  agents  of  this  kiad,  they  may  kill  speedily,  if  drunk  in  toogrea-. 
tjuantities;  and,  after  death,  the  vitality,  from  the  previous  great  action,  is  fouad 
completely  destroyed. 


26 

in  the  cure  of  inflammation,  unless  in  so  far  as  they  become 
the  vehicle  for  applying  cold.  The  surface  is  not  very  sus- 
ceptible of  their  action;  and,  therefore,  those  who  are  in- 
clined to  continue  their  use,  may  do  so  without  injury,  and 
even  with  benefit,  if  they  be  cold  ;  but  then  the  same  benefit 
will  be  derived  from  cold  water. 

Alcohol  is  likewise  considered  by  some  as  a  sedative,  and 
introduced  as  a  remedy,  in  the  enumeration  of  those  which 
are  applicable  in  inflammation  ;*  but,  whatever  its  use  may 
be  in  the  inflammatio  debilis,  it  must  be  allowed  to  be  evi- 
dently hurtful  in  the  inflammatio  valida. 

The  last  division  of  local  application,  contains  those  which 
tend,  both  simply  to  abate  action  in  general,  and  also  to  ex- 
cite, to  a  certain  degree,  a  specific  change  of  the  action.  To- 
pical bleeding  is  the  chief  remedy  belonging  to  this  division. 
Bleeding  with  leeches,  or  the  scarificator,  is  employed  in 
two  different  circumstances  :  First,  when  we  detract  directly 
from  the  inflamed  part ;  as,  for  instance,  from  the  surface  of 
a  phlegmon :  Secondly,  when  we  detract  only  from  the  neigh- 
bourhood of  the  inflamed  part ;  as,  for  instance,  from  the  skin 
which  covers  an  inflamed  joint.  When  we  employ  topical 
bleeding,  in  the  first  case,  we  may  suppose,  that  the  aper- 
ture, and  effusion  from  the  extremities  of  the  inflamed  ves- 
sels, produces,  to  a  certain  degree,  a  change  of  action.  Every 
action  of  the  vessels  is  performed  at  their  extremities,  and 
the  trunks  and  branches  may  be  considered  as  canals  subser- 
vient to  the  extremities,  and  which  contract  and  dilate,  in  a 
degree  proportioned  to  the  general  and  local  action.  If,  dur- 
ing health,  we  open  a  number  of  the  extremities  of  these  ves- 
sels, we  induce  the  hemorrhagic  action,  which  continues 
longer  or  shorter,  according  to  circumstances,  and  which 
gradually  terminates  in  a  serous  discharge,  or  secretion.    If, 

*  Hunter  ou  Inflammation,  p.  350. 


a 

during  inflammation,  we  open  a  number  of  the  extremities  oi 
vessels,  either  in  the  inflamed  part,  or  immediately  contigu- 
ous to  it,  we  induce  a  similar  hemorrhagic  action,  which  is 
different  from  the  inflammatory  one,  and,  therefore,  tends  to 
diminish  that  action  in  the  part.  We  likewise,  by  inducing 
the  serous  secretion,  tend  to  produce  a  termination  to  the  in- 
flammatory action. 

Topical  bleeding  will  also,  in  part,  operate,  by  simply 
abating  the  action,  in  consequence  of  the  mere  loss  of  blood  ; 
for,  as  the  blood  is  withdrawn  immediately,  by  different  ori- 
fices, from  the  vessels  of  one  part,  that  part,  and  those  near 
it,  may  be  supposed  to  suffer  sooner,  and  to  a  greater  degree, 
than  the  rest  of  the  system.  The  branches  which  yield  the 
blood,  will  even  suffer  considerably,  for  a  time,  although  the 
loss  of  blood  be  very  trifling,  and  produce  no  effect  on  the 
system.  Thus,  if  one  small  artery  be  divided,  we  find,  that, 
although  the  quantity  of  blood  which  flows  from  it  be  very 
inconsiderable,  yet  it  is  sufficient  to  produce  evident  changes 
rn  that  vessel,  making  it  contract,  and  become  smaller,  al- 
though the  vessels  in  other  parts  be  not  at  all  affected.  This 
depends  upon  the  peculiar*  action  of  the  individual  artery 
being  affected,f  and  the  contracting  state  of  the  orifice, 
spreading  along  the  branch  and  trunk  by  degrees,J  by  which 


*  By  peculiar  action,  I  do  not  here  mean  what  is  commonly  understood  by  the 
term  specific,  but  the  action  which  is  proper  to  the  artery,  considered  as  an  indivi- 
dual, in  opposition  to  the  action  of  the  heart  and  arteries,  considered  in  general  as 
an  entire  circulating  system  ;  for  one  part  of  this  system  may  act  less  powerfully 
than  another,  and  may  be  more  dilated,  &c. 

t  The  distance  to  which  this  will  extend,  depends  chiefly  upon  the  quantity  of 
blood  which  is  lost,  and  the  size  of  the  vessel  which  is  affected. 

}  This  depends  upon  the  operation  of  the  sympathy  of  association.  Sympathy 
was,  in  the  preliminary  dissertation,  divided  into  that  of  association,  and  that  of 
equilibrium;  and  it  was  mentioned,  that  the  same  parts  might  be  made  to  exhibit 
either  of  these,  but  that  naturally  the  sympathy  of  association  is  chiefly,  and 
most  easily  exhibited  by  those  parts  which  are  similar  in  structure,  and  contiguous 
to  each  other;  and,  in  them,  the  action  spreads  fastest.  At  the  same  time  if  the 
action  continues  long,  or  be  very  strong,  it  may  be  propagated  to  dissimilar  par'v, 

yor,.  n.  p 


20 

less  blood  is  made  to  circulate  through  it.  Bleeding  from  a 
vein,  however,  has  not  the  same  effect ;  because  the  quantity 
of  blood  in  a  part,  is  not  so  immediately  dependent  upon  the 
state  of  the  veins ;  and  because  veins  are  not  the  seat  of 
much  action.  When  we  divide  a  small  vein,  we  find,  that 
it,  by  degrees,  contracts,  and  transmits  less  blood,  or  closes 
completely ;  but  the  blood  from  the  part  does  not  circulate 
i'aster,  nor  is  less  blood  sent  to  that  part  than  formerly ; 
therefore,  topical  bleeding  from  veins  near  the  affected  part, 
can  have  no  great  superiority  over  general  bleeding. 

The  division,  then,  of  a  number  of  small  arteries,  may  cure 
inflammation  in  two  ways ;  first,  by  inducing  a  different  ac- 
tion; secondly,  by  possessing  Ihe  general  properties  of 
bleeding,  namely,  a  simple  diminution  of  action.  The  first 
will  operate  chiefly,  when  we  apply  the  leeches  on  part  of 
the  inflamed  portion.  The  second  will  operate,  when  we 
detract  only  from  the  immediate  vicinity ;  and,  in  this  case, 
the  quantity  of  blood  which  is  taken  away,  must  be  greater ; 
because  the  effect  has  to  be  extended  some  way,  the  vessels 
not  being  in  the  inflamed  part.  The  quantity  must  likewise 
be  greater,  because  the  effect  depends  entirely  upon  this  ; 
whereas,  in  the  other  case,  it  depended,  in  part,  upon  the  pe- 
culiarity of  the  action,  which  was  produced. 

The  number  of  leeches  which  it  is  necessary  to  apply, 
will  depend  upon  the  violence  of  the  action,  and  the  place 
on  which  they  are  set ;  for,  the  greater  the  distance  from 
the  inflamed  part,  the  more  numerous  ought  they  to  be.  It 
is  therefore  impossible  to  give  any  particular  rule  for  the 
extent  of  topical  bleeding.  It  may,  however,  be  proper  to 
observe,  that  we  ought  not  to  be  satisfied  with  one  applica- 


.iikI  produce  either  a  very  extensive,  or  an  universal  action,  which  is  just  a  great- 
er decree  of  the  sympathy  of  association.  In  this  case,  it  ha?,  however,  been  call- 
••d  universal  sympathy. 


29 

lion,  more  than  with  one  venesection,  for  a  general  disease 
but  ought  to  repeat  the  local  bleeding,  whenever  it  may  be 
necessary,  although  it  may  be  twice  or  thrice  in  a  day, 
founding  our  indications  upon  the  same  principle  on  which 
we  use  general  bleeding.  It  is  by  a  too  sparing  application  of 
leeches,  and  their  not  being  repeated  sufficiently  frequent, 
that  we  so  often  fail  in  removing  inflammations,  which,  by  a 
more  active  treatment,  we  might  resolve.  In  general,  the  leech- 
es ought  to  be  applied  as  near  the  affected  part  as  passible,  or 
upon  it.  If,  hoAvever,  the  seat  of  the  inflammation  be  chief- 
ly in  the  cutis,  as  in  erysipelas,  it  will  perhaps  be  more  prudent 
not  to  apply  them  upon  the  spot ;  because  the  subsequent 
irritation  is  apt  to  increase  the  action  afterwards,  on  account 
of  the  great  delicacy  of  the  part.  There  may  even  be  some 
doubt  as  to  the  propriety  of  applying  leeches  to  the  vicinity 
of  the  inflammation  ;  for  the  irritation  of  the  bites  may  pro- 
duce erysipelas  in  the  part,  or  cause  the  original  disease  to 
spread. 

The  scarificator  may  be  used  where  leeches  cannot  be 
obtained  ;  but  it  is  not  so  useful,  when  applied  to  the  inflam- 
ed part,  on  account  of  the  irritation  which  attends  its  appli- 
cation, and  the  cupping  ;  but  it  is  equally  proper,  where  we 
detract  not  from  the  part  itself,  but  from  its  vicinity. 

Of  the  topical  remedies,  bleeding  is  the  most  powerful ; 
and,  next  to  that,  cold  solutions  of  lead-  Where  these  can- 
not be  employed,  owing  to  the  internal  situation  of  the  in- 
flamed part,  blisters  must  be  used  in  their  place. 

Many  other  remedies  used  to  be  recommended,  under  the 
name  of  discutients,  repellants,  &c.  ;  some  of  which  have 
been  formerly  mentioned,  when  considering  the  ancient  the- 
ories of  inflammation  ;  these,  however,  are  now  laid  aside. 
Hut  many  practitioners  still  have  an  idea,  that  benefit  will 
foe  derived  from  mechanically  softenmg  the  paHs  by  mean- 


3G 

-of  oils,  or  what  they  call  emollients  ;  and  seem  to  consider 
that  poultices  are  chiefly  useful  for  the  same  purpose  ;  at 
least  they  only  direct,  that  they  shall  be  removed  before 
they  turn  "stiff  or  hard."  But  inflammation  must  be  at- 
tributed to  a  different  cause  than  increased  attrition,  and  its 
cure  must  be  effected  by  different  agents  from  those  which 
we  employ  for  softening  a  piece  of  dead  skin.  Oils  and  lini- 
ments, in  so  far  as  they  form  a  basis  for  other  applications,  or 
are  used  along  with  gentle  friction,  may  be  occasionally  proper 
in  the  inflammatio  assuefacta:  but  in  the  inflanimatiovalida, 
they  must  be  considered  as  absolutely  useless. 

There  are  also  some  remedies,  recommended  with  the  inten- 
tion of  absorbing  acrimonious  excretions ;  such  as,  flour  or 
magnesia,  in  erysipelas.  But  these  seem  to  act  entirely  by 
'  allowing  the  action  to  run  its  course,  without  interuption,  af- 
fording a  softer  defence  than  could  otherwise  be  obtained. 
From  the  quick  progress  of  violent  cuticular  inflammation, 
the  applications  which  are  usually  made  in  other  inflamma- 
tions have  been  forbid  here,  and  are  said  to  be  pernicious  ; 
but  this  rather  appears  to  arise  from  the  application  not  being 
properly  timed,  than  from  any  peculiarity  in  the  disease.  It 
is  not  easy  to  give  any  good  reason  why  cold  saturnine  solu- 
tion of  a  proper  weakness,*  and  sufficiently  early  applied, 
should  not  be  useful ;  nor  do  we  find,  that  they  are  in  reality 
hurtful  in  simple  erythema.  Where  this,  however,  attends 
wounds,  or  is  not  an  original  disease,  these  are  improper  ;  be- 
cause it  is  in  general,  in  these  cases,  an  attendant  upon  the 
inilammatio  debilis,  or  a  symptom  of  it,  and  requires  either 

*  The  solution  must,  upon  the  principles  already  laid  down,  be  both  weak, 
and  only  so  cold  as  to  reduce  the  sensation  of  the.pa.rt  to  its  natural  condition, 
that  is  to  say,  so  as  to  abate  the  morbid  feeling  of  heat;  because,  if  we  make  it 
otherwise,  we  may  injure  the  powers  of  recovery,  and  perhaps  induce  gangrene. 
•The  application  ought  not  to  be  so  cold  as  to  excite  the  sensation  of  coldness,  at 
least  in  any  considerable  degree 


31 

to  be  let  alone,  or  to  have  stimulating  applications  made  to  it, 
at  the  same  time  that  we  give  bark  internally.* 

These  remarks  upon  the  resolution  of  the  inflammatio  vali- 
da,  may  be  concluded,  by  observing,  that  the  diet  ought  to 
be  low  and  sparing,  in  a  degree  proportioned  to  the  violence 
of  the  action.  Such  motion  as  affects  the  local  action,  must 
at  all  times  be  prevented :  but  when  a  general  action  like- 
wise exists,  then  general  quietude  must  also  be  insisted  on. 

Of  the  Remedies  which  are  necessary  for  inducing 
Suppuration. 

Suppuration  is  a  new  action,  the  exciting  cause  of  which 
is  inflammation ;  but,  that  it  may  take  place,  it  is  requisite, 
that  the  inflammatory  action  be  prevented  from  subsiding  too 
soon,  or  too  suddenly ;  in  which  case,  either  resolution,  or 
inflammatio  assuefacta,  takes  place :  Whilst,  on  the  other 
hand,  we  must  prevent  the  action  from  rising  too  high,  and 
proceeding  too  rapic.ly  ;  in  which  case,  mortification  is 
caused. 

In  these  cases,  in  which  resolution  cannot  be  obtained,  sup- 
puration will  generally  take  place,  without  any  interference 
on  our  part,  provided  we  prevent  the  action  from  terminat- 
ing in  gangrene.  This  we  observe  in  many  internal  inflam- 
mations. At  the  same  time,  we  may  sometimes  accelerate 
this  process,  by  a  proper  regulation  of  the  original  action. 

The  remedies  proper  for  moderating  and  removing  the  in- 
flammatory action,  have  been  already  mentioned;  but  these 
sometimes  fail  to  produce  resolution ;  in  which  case,  either 


*  Bark  is  useful  and  necessary  in  every  case  of  erysipelas,  after  the  inflammatio 
valida  has  abated-  Local  applications,  of  a  stimulating  nature,  are  also  useful 
at  this  period,  as  will  afterwards  be  mentioned,  when  the  inflammatio  debiljs 
comes  to  be  considered, 


32 

suppuration,  or  mortification,  takes  place.  When  the  symp- 
toms of  suppuration  take  place,  (which  have  been  already  no* 
ticed,)  all  that  is  perhaps  essentially  necessary,  is,  to  give  up 
the  resolving  plan,  and  not  interrupt  the  natural  progress  of 
the  action.  If,  however,  the  inflammatory  action  continue 
longer  stationary,  and  seem  neither  to  be  resolving,  nor  de- 
cidedly inducing  the  suppurative  action,  then  such  remedies 
as  increase  the  action,  and  accelerate  its  progress,  are  essen- 
tially requisite.  These  remedies,  however,  are,  in  general, 
indiscriminately  applied  in  both  cases. 

For  the  purpose  of  inducing,  or  accelerating  the  suppura- 
tive action,  it  was  formerly  the  practice  to  apply  liniments, 
cataplasms,  and  fomentations,  composed  of  stimulating  sub- 
stances, such  as  garlic,  turpentine,  galbanum,  .Scc^  but  of  late 
these  have  been  almost  entirely  abandoned.  Heat  and  elec- 
tricity have  the  property  of  increasing  the  performance  of 
every  action  which  is  existing  at  the  time  of  their  applica- 
tion, and,  therefore,  are  the  remedies  chiefly  to  be  employ- 
ed in  the  present  instance. 

Heat  may  be  applied  in  two  ways,  with  or  without  mois- 
ture. In  the  first,  it  increases  action  more  suddenly,  and 
perhaps  more  simply.  In  the  second,  its  effects  are  more 
gradual,  and  are  likewise  complicated  with  those  of  moisture, 
which  certainly  is  an  agent  capable  of  operating  on  the  liv- 
ing system,  and  generally  tends  to  excite  a  secretory  action, 
or  to  give  a  secretory  termination  to  those  increased  actions, 
which  are  induced  by  agents  operating  along  with  it.  Dry 
heat  is  therefore  evidently  improper  in  the  inflammatio  vali- 
da,  because  it  will  tend  to  produce  mortification ;  but,  if  mois- 
ture be  conjoined,  then  the  suppurative  action  is  excited. 
When,  hoAvever,  the  action  has  made  an  approach  to  the  in- 
flammatio assuefacta,  then  it  may  be  useful  to  raise  the  action 
simply  by  dry  heat,  for  a  little,  before  we  apply  heat  and 
moisture ;  because,  if  we  apply  moisture  at  first,  the  pro 


33 

gress  is  more  tedious,  and  the  action  is  less  certainly  excit 
ed.*  Electricity  is  similar  in  its  operation  to  heat  and  dry- 
ness, and  may  be  usefully  employed  in  similar  cases ;  but 
we  must,  if  we  expect  any  benefit,  repeat  its  operation  fre- 
quently, and  continue  each  application  for  a  considerable 
time.f 

There  are  two  forms  in  which  we  employ  heat  and  mois- 
ture, namely,  fomentations  and  poultices.  Fomentations]: 
have  this  superiority  over  poultices,  that  the  same  degree  of 
heat  is  always  kept  up' during  their  application;  whereas, 
when  we  use  poultices,  the  heat  subsides,  as  they  are  renew- 
ed only  at  considerable  intervals ;  but  fomentations  require 
longer  attendance,  and  more  trouble ;  and,  therefore,  are  on- 
ly employed  for  a  short  time,  and  commonly  betwixt  the  in- 
tervals at  renewing  the  poultices. 

Poultices  are  generally  made  of  bread  and  milk  boiled  to- 
gether, so  as  to  form  a  thick  kind  of  paste,  to  which  is 
added,  so  much  olive  oil  as  will  preserve  it  from  hardening 
quickly.^  These  ought  to  be  applied,  either  of  the  same 
temperature  with  the  inflamed  part,  or  hotter,  according  to 
circumstances.  When  the  inflammation  seems  to  be  natu- 
rally and  quickly  tending  toward  suppuration,  it  is,  as  has 
been  already  mentioned,  by  no  means  essential,  that  any  ap- 


*  From  what  has  been  said  in  the  preliminary  dissertation,  we  may  understand 
how  moisture  should  tend  to  induce  a  secretion.  Agents  frequently  excite  condi- 
tions somewhat  similar  to  their  general  properties :  Thus,  putrid  matter  tends  to 
induce  the  action  of  descent,  and  consequent  putrefaction.  We  likewise  experi- 
mentally find,  that  if  moisture  be  applied  during  a  general  increased  action,  it  in- 
duces perspiration,  unless  it  be  conjoined  with  cold,  which  lessens  the  action. 

t  The  proper  way  to  use  electricity,  in  this  case,  is  to  draw  scintillae  from  the 
part,  the  patient  being  insulated. 

{  Fomentations  are  made,  by  applying  a  soft  cloth,  dipped  in  any  warm  fluid, 
(commonly  water)  to  the  part.  Sometimes  the  cloth  is  wrung  hard,  in  which  case 
it  is  chiefly  steam  which  is  applied. 

J  Poultices  may  also  be  made,  by  boiling  pounded  linseed-cake,  orfrom  potatoes, 
or  mashed  vegetable  leaves  (which  are  the  cheapest  for  hospitals,)  such  as  tussila- 
r.«,  4c. 


34 

plication  be  made  externally,  in  order  to  induce  the  suppu 
rative  action  ;*  but  still  poultices  are  used,  and,  in  many 
cases,  accelerate  the  progress.  In  this  case,  the  poultices 
should  only  be  applied  so  hot  as  not  to  give  any  considera- 
ble sensation  of  heat,  otherwise  we  increase  the  action  too 
much,  and  too  rapidly,  and,  if  early  employed,  may  even 
interrupt,  or  stop  the  incipient  purulent  action,  renewing 
the  inflammation,  and  perhaps  making  it  terminate  in  partial 
gangrene.  Poultices,  then,  should  not  be  applied  very  hot 
at  first,  especially  when  the  action  seems  to  be  such  as  to 
make  us  expect  that  it  shall  run  its  course  without  any  as- 
sistance. But  when  the  inflammatory  action  has  been  more 
tedious,  and  does  not  terminate  in  the  suppurative  one  so 
soon,  and  so  decidedly  as  we  would  wish,  then  poultices 
must  be  applied,  with  a  different  intention,  being  meant,  not 
solely  to  prevent  the  action  from  sinking,  as  in  the  first  case, 
but  also  to  raise  it,  and  make  it  brisker.  The  heat  must 
therefore  be  greater,  and  such  as  to  give  a  considerable  sen- 
sation ;  and  the  poultices,  instead  of  being  changed  only 
when  they  begin  to  grow  hard,f  which  is  perhaps  all  that 
is  necessary  in  the  first  case,  must  be  renewed  very  fre- 
quently, in  order  to  keep  up  the  increased  degree  of  heat,  or 
the  agent  which  supports  the  action,  and  accelerates  its  pro- 
gress. They  ought,  in  this  case,  to  be  taken  off  and  warm- 
ed or  renewed  almost  every  hour,  at  least  when  the  action  is 


*  The  inflammatory  action,  when  moderately  strong,  acts  naturally  as  an  ex- 
citing cause,  inducing  the  purulent  action,  which  is  therefore  said  to  be  a  termina- 
tion of  inflammation.  It  is  therefore  as  unnecessary  to  interfere  in  the  produc- 
tion of  this  secretion,  when  the  action  is  of  proper  strength,  &c.  as  it  would  be  to 
attempt  to  increase,  by  local  means,  the  vesication  which  is  produced  by  a  blister. 
Poultices  are,  in  this  condition,  perhaps  chiefly  useful,  by  removing  the  causes 
which  tend  to  abate  the  action  at  an  improper  time,  such  as  those  which  produce 
resolution,  as  cold,  &c. 

f  They  keep  up  the  heat  of  the  part,  and  keep  it  moist  until  this  happens,  and 
prevent  the  action  from  flagging  suddenly,  which  is  all  that  is  required  of  them, 
wheii  the  action  is  going  on  of  itself  in  a  proper  decree. 


35 

tedious,  that  is  to  say,  when  they  are  most  required.     We 
are  then  not  to  lay  down  any  certain  degree  of  heat  which 
is  to  be  employed,  nor  fix  any  particular  number  of  times  at 
which  the  poultices  must,  in  every  instance,  be  changed, 
but  regulate  our  practice  entirely  by  the  nature  of  each  par- 
ticular instance,  taking  the  progress  and  degree  of  the  action 
as  our  guide,  in  this  respect,  and  interfering  exactly  in  pro- 
portion to  the  necessity  for  interference.     It  may  not,  how- 
ever, be   improper   to   remark,    that,  caeteris   paribus,  the 
heat  must  be  greater  in  proportion  to  the  depth  of  the  in- 
flamed part  below  the  skin ;  or,  in  other  words,  we  must  ap- 
ply more  heat,  when  we  are  obliged  to  act  on  a  part  not  yet 
inflamed,   than  when  we  act  directly  on  the  inflamed  part 
itself.     When  an  abscess  forms  at  a  distance  from  the  sur- 
face, the  parts  betwixt  it  and  the  surface  gradually  come,  as 
was  formerly  mentioned,  to  assume  the  purulent  action  ;  and 
the  sympathy  of  equilibrium,  which  naturally  exists  betwixt 
the  surface  and  the  parts  below,  gives  way  to  the  sympathy 
of  association,*  the  parts  coming  by  degrees,  to  perform  one 
uniform  action  together,  which  spreads  from  within  to  with- 
out.    When  we  apply  heat  to  the  surface,  at  this  place,  we, 
by  continuance,  likewise  induce   the  sympathy  of  associa- 


*  When  two  parts  are  affected  at  the  same  time,  in  consequence  of  an  agentope- 
rating  quickly  on  one  of  them,  they  commonly  exhibit  the  sympathy  of  association, 
which  takes  place  suddenly,  but  generally  at  first  lasts  only  for  a  short  time,  if  the 
parts  be  distant ;  but,  if  the  original  disease  still  continue,  it  may  spread,  inch  by 
inch,  until  it  arrives  at  the  part  which  was  formerly  affected,  and  which  i3  again 
aflected  more  permauehtly,  by  the  same  kind  of  sympathy  taking  place,  but  in  a 
different  way.  In  the  first  case,  we  have  the  sympathiaconsociationis  intermpta; 
in  the  second,  the  sympathia  consociationis  serpens.  It  is  this  last  which  is  the 
cause  of  the  cxten.-ion  of  all  action  in  a  part,  and  which,  when  strongly  excited, 
overcomes  the  natural  tendency  to  the  exhibition  of  the  sympathy  of  equilibrium. 
It  is,  bowever,  more  difficult  for  local  action  to  spread  by  degrees  to  parts  which 
evince  the  sympathy  of  equilibrium  than  other  part? ;  and  these,  in  general,  are 
longer  of  being  affected.  Thus,  when  inflammation  begins  in  the  skin,  it  can  much 
more  easily  spread  along:  the  skin  than  dip  down  to  the  muscles. 

VOL.    II.  E 


36 

tion,  and  the  increased  action  spreads  and  operates  on  the 
disease ;  but  there  is  this  difference,  that  the  action  of  the 
heat  spreads  from  without  to  within,  and  thus  accelerate* 
the  progress  of  the  suppurative  action. 

When  the  suppurative  action  has  existed  a  certain  time, 
we  find,  that  it  gradually  extends  itself  to  the  skin,  purulent 
matter  being  formed,  instead  of  organic  particles  ;  on  which 
account,  the  cavity  enlarges,  and  the  covering  becomes  daily 
thinner.  At  last,  the  action  reaches  even  to  the  cutis, 
which  becomes  white  and  flaccid,  first  at  a  point,  and  then 
to  a  greater  extent.*  When  this  happens,  the  thin  covering 
is  either  torn  by  the  pressure  of  the  contained  fluid,  acted  on 
-by  the  surrounding  parts,  or  acting  by  its  own  weight ;  or, 
if  this  does  not  take  place,  the  suppurative  action  still  pro- 
ceeds going  through  the  cutis,  the  organization  of  which, 
like  that  of  the  parts  below,  is  lost :  The  thin  cuticle  now 
rises  up  into  a  little  blister,  and  then  gives  way.  The  mat- 
ter runs  gradually  out,  the  sides  collapse,  and  come  nearer 
by  degrees  to  each  other,  at  the  same  time  that  the  ulcera- 
tive action  succeeds  to  the  suppurative.  The  quantity  of 
the  discharge,  therefore,  daily  lessens  ;  the  internal  surface, 
or  sides  of  the  abscess,  come  in  contact ;  and  the  granula- 
tions at  the  margin  or  circumference  unite  ;  those  belonging 
to  one  side  uniting  with  those  of  the  other,  and  thus  pro- 
ducing recovery  by  successive  circles  of  reunion,  which 
form  rapidly,  or  more  slowly,  according  to  circumstances. 

Such  is  the  natural  progress  of  an  abscess  ;  but  it  has 
been  proposed,  that  it  ought  not  to  be  allowed  to  follow  this, 
but  ought  to  be  opened  before  it  bursts  spontaneously  ;  and 


*  In  proportion  as  the  action  extends  outward,  it  also  becomes  more  concentra- 
ted. An  abscess  is  therefore  somewhat  conical,  or  at  least  hemispherical,  the 
base  being  turned  inward,  and  the  apex  outward.  When  the  action  reaches  the 
surface,  it  is  first  at  a  single  point ;  but,  by  degrees,  it  becomes  extended,  and  the 
.1  Dex  becomes  broader. 


37 

this  opening  has  generally  been  desired  to  be  pretty  large, 
chiefly  perhaps  on  the  principle  of  allowing  a  free  evacua- 
tion of  the  matter.  Where  abscesses  are  seated  over  cavi- 
ties into  which  they  may  burst,*  instead  of  opening  exter- 
nally, there  can  be  no  doubt  of  the  necessity  of  making  an 
early  evacuation  ;  and,  in  these  cases,  we  ought  to  open  them 
before  the  skin  becomes  white ;  or,  in  other  words,  before 
the  action  reaches  the  surface ;  because,  if  the  abscess  be 
seated  equally  betwixt  the  skin  and  the  cavity  below,  we 
may  suppose,  that,  if  it  be  extending  itself  in  all  directions, 
or  toward  the  cavity, f  in  the  same  proportion  as  outwardly, 
that  the  parts  below  will  become  almost  irreparably  diseased 
before  it  can  reach  the  surface,  and  will  give  way  afterwards, i 
even  although  an  opening  be  made  externally.  Where, 
from  the  confinement  of  the  matter,  it  seems  to  be  spread- 
ing, or  diffusing  itself,  by  its  gravity,  through  the  cellular 
substance,  or  among  the  muscles,  it  will  likewise  be  necessa- 
ry to  open  the  abscess  early  ;  but,  in  this  case,  the  abscess 
is  unhealthy  ;  for,  were  it  otherwise,  the  matter  would  be 
confined  by  the  circle  of  diseased  organic  matter  thrown  out 
during  the  inflammatory  action,  and  which  is  only  removed 


*  Such  as  the  thorax,  trachea,  &c.  Instances  have  happened  of  suffocation  be- 
ing thus  produced. 

f  Although,  in  general,  an  abscess  has  little  tendency  to  extend  itself  deep 
down,  but  rather  moves  toward  the  surface,  although  so  far  from  it  originally, 
that,  had  the  action  extended  equally  in  all  other  directions,  the  size  of  the  ab- 
scess must  have  been  immense;  yet,  when  it  is  situated  over  a  cavity,  it  may  pro- 
ceed toward  that  as  if  to  an  external  surface.  Even,  however,  in  this  case,  the 
general  law,  of  all  actions  tending  to  the  skin,  obtains ;  for  the  progress  outward 
is  much  quicker  than  that  inward  ;  but,  if  the  action  commenced  near  the  surface 
of  the  cavity,  as  is  commonly  the  case,  the  difference  of  the  distance  will  com- 
pensate for  the  superior  tendency  to  extend  outward  ;  and,  therefore,  the  abscess 
may  burst  at  the  internal  surface  into  the  cavity. 

i.  In  abscesses  seated  on  the  thorax,  I  have  known  the  intercostal  muscles  and 
pleura  continue  the  suppurative  action,  after  the  external  surface  had  opened,  31;'-} 
thus  an  opening  came  to  be  formed  into  the  thorax. 


gradually;  In  this  case,  the  suppurative  action  has  extend- 
ed itself  laterally,  and  perhaps  downward,  more  quickly  than 
in  health,  and  has  not  observed  the  same  ratio,  with  regard 
to  the  extension  toward  the  surface  ;  the  action,  therefore, 
reaches  parts  which  were  not  formerly  inflamed  (by  the 
sympathia  consociationis  serpens,)  before  the  surface  gives 
way ;  and,  therefore,  the  matter  spreads  or  diffuses  itself  5 
for,  by  the  spreading  of  the  action,  the  confining  barrier  is 
removed,  and  the  matter  mechanically  extends  itself.  This 
is  an  unhealthy  abscess,  and  the  action  is  of  the  phagedenic 
nature.  Opening  the  abscess  will  not  always  stop  this  mor- 
bid action ;  but,  by  removing  the  matter,  it  will  lessen  the 
chance  of  diffusion.  We  must,  however,  continue  the  free 
evacuation,  and  place  the  member  in  a  proper  posture  ;  be- 
cause, if  the  action  continue,  the  matter  which  still  is  form- 
ed will  lodge,  and  form  sinuses. 

In  healthy  abscesses,  where  we  do  not  apprehend  any  de- 
triment to  the  neighbouring  parts,  the  question  comes  to  be, 
whether  opening  them  will  accelerate  the  cure  ?  Perhaps 
much  of  the  diversity  of  opinion  on  this  subject,  has  arisen 
from  .'lot  attending  to  the  condition  of  the  abscess  which  we 
have  been  managing,  and  thus  we  apply  the  prognosis  and 
treatment  of  one  kind  of  abscess  to  different  ones.  When 
an  abscess  has  been  formed  slowly,  and  runs  its  course  rather 
tediously,  we  may  suppose,  that  the  action  shall  continue  for 
a  considerable  time  without  being  converted  into  the  ulcera- 
tive one  ;  and,  therefore,  the  abscess  shall  remain  long  with- 
out healing.  In  this  case,  a  free  incision,  or  the  irritation  of 
a  foreign  body,  may  excite  the  ulcerative  action,  and  thus 
accelerate  the  cure ;  for  these  abscesses  have  come  to  ap- 
proach toward  the  nature  of  common  encysted  tumors,  and 
require  the  same  treatment.  But,  where  abscesses  are  run- 
ning their  progress  with  due  celerity,  and  the  action  is  pro- 
ceeding through  its  proper  course,  there  is  not  the  same 


39 

cause  for  interference.  If,  in  this  case,  we  open  them  before 
the  action  has  gained  the  surface,  we  derive  no  benefit  ;  be- 
cause the  action  still  proceeds,  and  the  same  events  and  cir- 
cumstances take  place  as  if  we  had  allowed  it  to  burst.  If 
we  make  a  large  aperture,  when  the  abscess  i*  ready  to  burst, 
we,  by  the  irritation,  interfere  with  the  process  which  was 
going  on,  and  delay  the  cure.  The  admission  of  the  air  to 
the  abscess,  owing  to  the  free  exposure,  is  one  cause  of  this 
delay;  for  it  changes  the  nature  of  the  purulent  action,  and, 
if  the  ulcerative  action  takes  place,  frequently  renders  it  un- 
healthy ;  the  consequence  of  which,  if  the  abscess  be  large, 
or  situated  in  vital  parts,  is  hectic.  We  likewise,  in  large 
abscesses,  by  the  sudden  evacuation  of  the  matter,  and  re- 
moval of  the  distension,  sink  the  action  of  the  parts,  and 
make  recovery  more  tedious.*  When  the  absce>;,  then,  is 
healthy,  and  the  action  strong,  it  will  be  more  proper  to  al- 
low it  to  follow  its  natural  course,  and  burst  spontaneously, 
than  open  it,  by  a  large  incision,  or  by  the  introduction  of  a 
seton :  If  we  do  open  it,  the  orifice  should  not  at  iret  be 
Jarge,  but  should  just  comprehend  the  diseased  or  whitened 
surface. 

Sometimes,  after  an  abscess  has  burst,  or  been  opened,  it 
continues  in  a  progressive  state  of  amendment  for  some 
time,  and  then  becomes  stationary,  continuing  to  dischurze 
matter  without  healing.  This  either  takes  place  from  the 
whole  surface,  or  from  a  particular  part  of  it,  forming  a  sinus, 
the  treatment  of  which  will  afterwards  be  mentioned,  being 
the  same  with  those  which  succeed  ab-i  o--e>  which  are  ori- 
ginally unhealthy. 

After  an  abscess  bursts,  the  proper  application  is  a  warm 
poultice,!  which  should  be  continued  in  general  as  long  as 

*  This  likewise  affects  the  system,  and  produces  syncope,  if  the  mechanical 
support  be  withdrawn  suddenly  from  the  pans. 

f  This  poultice  does  not  require  to  be  so  ho',  re:  c'.iiriitd  so  frequently,  si 
befere  the  full  formation  of  matter. 


40 

there  is  any  stool,  or  hard  margin;  that  is  to  say,  until  the 
increased  quantity  of  diseased  organic  particles,  which  were 
formed  during  the  inflammation,  be  absorbed,  and  the  vessels 
at  that  part  have  either  assumed  the  suppurative  or  natural 
action.  After  this,  the  orifice  ought  to  be  covered  with  a 
slip  of  lint,  and  moderate  pressure  applied  over  the  surface 
of  the  abscess,*  by  which  the  sides  are  kept  in  constant 
contact,  and  reunion  is  accelerated.  Good  diet  is  also  ne- 
cessary, for  we  thus  increase  the  powers  of  recovery,  or 
keep  up  a  proper  action,  and  renew  the  vital  principle,  the 
quantity  of  which  has  been  lessened  during  the  inflammation, 
both  by  the  continuance  of  a  state  of  overaction,  and  by  the 
remedies  which  are  employed  to  diminish  the  action  ;  for  a 
state  of  real  and  permanent  weakness  is  thus  induced. 

It  sometimes  happens,  that  suppuration  takes  place  very 
slowly,  and  the  action  seems  to  be  performed  with  little  vi- 
gour. In  this  case,  if  the  abscess  be  allowed  to  burst  of  it- 
self, we  both  lose  time,  and  are  often,  in  the  end,  disappoint- 
ed in  a  cure,  the  healing  process  not  taking  place.  It  is 
therefore  useful,  in  these  cases,  to  have  recourse  to  other 
agents  besides  heat.  If  the  pain  be  trifling,  and  the  suppu- 
ration be  what  may  be  called  chronic,  or  approaching  to  it, 
we  will  perhaps  succeed,  by  applying  gentle  pressure  on  the 
abscess,  by  means  of  a  thin  roller,  and  laying  a  warm  poul- 
tice over  this.  But,  when  this  fails  to  increase  the  action, 
we  ought  to  pass  a  seton,  by  which  we  evacuate  the  matter, 
and  keep  up  the  subsequent  action  to  a  degree  sufficient  for 
producing  recovery.  In  doing  this,  however,  it  is  necessary 
to  attend  to  the  state  of  the  tumor ;  because,  if,  in  every  in- 
stance, we  pass  it  from  the  highest  to  the  lowest  part,  we 
shall  sometimes  make  the  part  give  way  in  a  third  place.  If, 


*  If  this  produces  pain,  we  may  in  general  conclude  that  it  has  been  used 
too  goon. 


41 

tor  instance,  the  abscess  be  much  thinner  at  the  apex  than 
elsewhere,  or,  if  the  action  have  made  considerable  progress 
toward  the  surface,  then  the  stimulus  of  the  action  increases 
the  performance  of  the  natural  process  which  was  going  on, 
and  the  action  continues  to  extend  itself  until  the  part  gives 
way.  In  these  cases,  then,  we  ought  to  pass  the  seton  from 
the  thin  part  to  the  lowest  part ;  and  this,  in  general,  will, 
from  the  sympathy  of  association,  be  sufficient  to  excite  the 
action  of  the  whole  internal  surface. 

When  we  resolve  to  use  the  seton,  the  following  is  the 
easiest  method  of  introducing  it :  Make  a  puncture  with  a 
lancet  either  into  the  upper,  or  the  thinnest,  and  most 
prominent  part  of  the  tumor,  according  to  circumstances  ; 
and,  into  this  puncture,  introduce,  using  the  lancet  as  a  di- 
recter,  a  probe,  having  a  piece  of  tape  passed  through  its 
eye.  The  lancet  is  then  to  be  withdrawn,  and  the  probe 
pushed  down  to  the  under  part  of  the  abscess,  where  its 
point  will  be  felt  under  the  skin.  A  small  incision  is  here 
to  be  made  upon  the  knob  of  the  probe,  which  is  next  to  be 
passed  through,  and  the  tape  drawn  after  it.  The  matter  is 
then  to  be  slowly  pressed  out ;  the  tape  is  to  be  folded ;  and 
the  abscess  bound  up  with  a  compress  and  roller,  so  as  to 
make  moderate  pressure  upon  it.  Next  day,  the  dressings 
are  to  be  removed,  and  a  clean  piece  of  the  tape  drawn 
through,  after  which,  pressure  is  again  to  be  applied. 

The  size  of  the  tape,  the  time  which  the  seton  ought  to 
be  employed,  and  the  degree  of  pressure  to  be  used,  must 
be  regulated  by  backwardness  of  the  action,  and  the  imper- 
fection of  the  healing  process. 

If,  either  from  improper  management,  or  the  morbid  cond: 
tion  of  the  action,  the  abscess,  after  it  bursts  spontaneously,  or 
is  opened  by  art,  continue  to  suppurate,  without  undergoing 
the  ulcerative  action  preparatory  to  healing,  then  we   find, 


that  either  the  sides  remain  quite  separate,  producing  a 
cavity,  extended  more  or  less,  or  one  particular  portion  re- 
mains open,  forming  a  sinus.  Both  of  these  cases  require  a 
treatment,  which  in  its  principle,  is  the  same,  namely,  the 
indication  of  the  ulcerative  action. 

In  the  first  case,*  we  shall  frequently  succeed  by  means 
of  the  seton,  especially  if  we  use  pressure  along  with  it  ; 
for,  by  keeping  the  internal  surface  in  close  contact,  we  tend  to 
check  the  purulent,  or  suppurative  action,  and  produce  orga- 
nic particles.f  We  may  also  succeed,  by  using  stimulating 
injections,  of  such  a  strength  as  to  produce  a  moderate  de- 
gree of  smarting.  Of  this  kind  are,  wine  and  water,  solu- 
tions of  white  vitriol,  corrosive  sublimate,  &c.  These  ought 
to  be  used  frequently  in  the  course  of  the  day,  and  pressure 
employed  during  the  intervals.  Incision,  or  laying  the  part 
open,  is,  being  the  most  severe,  the  last  remedy  which  is  to 
be  had  recourse  to.  Small  chronic  abscesses  may  be  laid 
open  during  their  whole  diameter ;  but  larger  ones  require 
only  to  be  cut  up  for  a  certain  length. 

The  second  case,  has  generally  been  considered  as  a  spe- 
cies of  ulcer,  and  has  been  named  the  sinus  ulcer ;  but,  al- 
1  hough  the  orifice  may  sometimes  possess  the  diseased  ulce- 
rative action,  yet  the  sinus  itself  still  continues  in  the  suppu- 
rative state,  and,  therefore,  cannot  heal.  These  sinuses  de- 
pend, in  different  instances,  upon  very  different  causes,  and, 
therefore,  require  a  variation  in  the  treatment.  The  most 
simple  species  of  sinus  may  be  called  mechanical,  and  is  pro- 


*  This  is  exactly  similar  to  an  encysted  tumour  which  has  been  opened,  and  re- 
quires the  same  treatment.  The  internal  surface  becomes  thick  and  somewhat, 
j;ard,  like  that  of  a  cyst.  It  differs  from  an  encysted  tumour  only  in  its  cause  and 
origin. 

f  If  pressure  be  employed  early,  to  a  considerable  degree,  the  irritation  of  the 
means  employed  produces  pain,  and  a  morbid  increase  of  action,  unless  we  keep 
down  the  action  by  cold,  as  will  be  explained  when  considering  the  treatment 
of  ulcers. 


43 

duced  by  matter  flowing  from  a  neighbouring  cavity,  and 
which  cannot  be  freely  discharged:  Thus,  for  instance,  if  a 
deep  abscess  open  at  the  highest  part,  or  at  a  point  above  the 
level  of  its    bottom,  the  matter  constantly  oozes   out,  and 
keeps  the  canal  open.     This  is  most  apt  to  occur,  when  ab- 
scesses are  formed  deep  among  muscular  parts  ;  in  which 
case,  although  the  matter  point  at  the  centre,  yet  an  accu- 
mulation must  take  place  below,  and  the  matter  must  conti- 
nue to  be   discharged  by  the  aperture,  when  it  becomes  so 
abundant  as  to  be  raised  to  the  level  of  the  opening ;  or,  be- 
ing once  raised,  it  continues  to  flow  out.     The  cure  of  this 
may  at  first  be  attempted  mechanically,  by  tight  bandages, 
which  press  out  the  matter,  and  keep  the  sides  in  contact ; 
but,  if  the  disease  have  been  of  long  duration,  then,  whatever 
may  have  been  its  nature  at  first,  we  find,  that  the  suppurative 
action  extends  along  the  mechanical  sinus,  which  then  be- 
comes affected  with  a  chronic  action ;  in  which  case,  it  be- 
comes similar  to  the  second  species  of  sinus.     We  must,  in 
this  species,  make  an  opening  at  the  most  dependent  part, 
and  employ  the  means  which  will  be  now  mentioned  in  consi- 
dering the  second  species,  or  that  produced  in  consequence 
of  the  suppurative  action  becoming  chronic  or  habitual,  in- 
dependent of  any  mechanical  cause.     This  may  take  place, 
although  the  aperture  have  been  originally  in  a  proper  place, 
and  the  matter,  instead  of  being  retained,  and  keeping  up  the 
disease,  shall  have  been  regularly  discharged.     The  case  in 
which  this  is  most  likely  to  happen,  is  that  in  which  the  abscess 
has  been  very  tedious  in  its  progress,  and  the  action  has  been 
from  the  first,   slow.     The  distinction  betwixt  this  species, 
and  those  which  remain  to  be  mentioned,  is  founded  upon  the 
absence  of  the  symptoms  which  they  possess,  and  by  our  ex- 
amination with  the  probe,  which  points  out  the  cause  and  ex- 
tent, and  informs  us  whether  we  be  near  a  bone.     The  orifice 
is  flabby,  and  has  the  appearance  of  the  indolent  ulcer.     The 

VOL.    II.  F 


44 

cure  of  these  sinuses  is  to  be  attempted,  by  pressing  out  the 
matter  by  means  of  proper  bandages,  or  by  making  a  depen- 
dent opening,  which  is  generally  necessary,  at  the  same  time 
that  we  raise  the  action  of  the  part  to  a  proper  degree,  and 
render  the  suppurative  action  acute  and  vigorous  ;  in  which 
ease,  it  naturally  terminates  in  the  ulcerative,  and  thus  the 
part  has  its  structure  restored.  This  is  most  easily  effected, 
by  passing  a  seton,  and  applying  a  proper  degree  of  pressure, 
diminishing  the  size  of  the  seton  gradually,  and  in  proportion 
to  the  vigour  of  the  action  and  the  approximation  toward 
health.  When,  from  the  situation  of  the  sinus,  Ave  cannot 
pass  a  seton  (which  rarely  happens  in  this  species  of  sinus,)  in- 
jections of  wine  may  be  used  frequently,  and  pressure  ap- 
plied during  the  intervals.  When  these  means  fail,  which  is 
seldom  the  case,  the  part  should,  if  its  structure  permit,  be 
laid  open.  If  this  sinus  have  remained  long  open,  its  surface, 
like  that  of  the  chronic  abscess,  becomes  changed,  and  a 
coat  is  formed  like  the  cyst  of  a  tumour.  When  this  is  thick 
and  hard,  the  sinus  has  been  called  a  fistula,  and  it  has  been 
deemed  necessary  to  dissect  out  the  tube ;  but  it  is  in  gene- 
ral sufficient  to  use  the  remedies  which  increase  the  vigour 
of  the  action,  and  make  it  run  its  natural  progress ;  such  as 
the  seton,  or  a  free  incision,  if  the  parts  be  superficial,  or 
no  considerable  vessel  or  nerve  runs  the  risk  of  being  wound- 
ed. 

The  third  species  of  sinus  is  that  in  which  the  suppura- 
tive action  is  kept  up  by  the  operation  of  some  adventitious 
cause  ;  such  as  a  caries  bone,  diseased  cartilage,  or  the 
lodgement  of  a  foreign  body ;  as,  for  instance,  a  ball,  a  splin- 
ter of  wood,  bit  of  cloth,  &c.  This  species  is  distinguished 
by  our  feeling  the  extraneous  body,  or  diseased  bone,  with 
the  probe,  and  by  the  fungous  protuberance,  or  papilla,  which 
shoots  out  from  the  orifice,  In  addition  to  the  method  of  cur- 


45 

ip.g  other  sinuses,  we  must  here  endeavour  to  remove  the 
adventitious  cause,  which  is  generally  very  difficult  to  be 
done.  If  the  foreign  body  be  deep,  or  if  the  diseased  bone 
lie  deep,  and  the  sinus  be  narrow,  we  can  do  little  in  this 
way ;  sometimes,  indeed,  by  enlarging  the  external  part,  we 
can  come  at  the  foreign  body  with  a  pair  of  small  forceps, 
and  may  extract  it,  or  may  accelerate  the  exfoliation  of 
the  diseased  bone  ;  but  we  can  have  no  certainty  of  suc- 
cess. If,  however,  the  sinus  be  superficial,  which  sometimes 
happens  in  caries  of  the  tibia,  &c.  it  ought,  in  every  instance, 
to  be  fully  laid  open,  and  the  bone  exposed,  and  treated  in 
the  way  immediately  to  be  mentioned.  When  this  cannot 
be  done,  we  may  sometimes,  by  conveying  the  proper  reme- 
dies through  a  tube  down  to  the  bone,  procure  exfoliation  ;  or 
may  by  setons,  injections,  and  pressure,  procure  a  tempora- 
ry cure  ;  but,  as  long  as  the  adventitious  cause  remains,  we  can- 
not expect  a  permanent  recovery.  It  is  observed,  that  sinu- 
ses, when  they  can  be  healed  in  these  circumstances,  break 
out  again  upon  very  trifling  exertions,  and  very  frequently 
are  renewed,  after  a  short  interval,  in  spite  of  all  our  precau- 
tions ;  such  as  rest,  warmth,  &c. 

A  caries*  of  the  bone  is  at  all  times  a  disease  which  is 
difficult  to  manage,  both  on  account  of  the  mechanical  ob- 
stacles which  we  have  to  overcome,  and  the  slowness  with 
which  the  affected  parts  perform  their  actions  either  of  dis- 
ease or  recovery.  The  divisions  of  this  disease  have  gene- 
rally been  taken  from  the  appearance  of  the  caries,  and  its 
extent.     We  have  the  dry  caries,  the  worm-eaten  caries,  the 


*  When  a  bone  becomes  carious,  the  periosteum  is  completely  detached,  and, 
therefore,  it  is  felt  to  be  rough  by  the  probe.  Its  colour  becomes  first  of  a  dull 
white,  or  dirty  yellow,  which  it  either  preserves,  or  changes  for  the  intermediate 
hues  betwixt  these  and  black.  It  is  generally  more  porous  than  formerly,  and 
lighter;  but  these  qualities  vary,  from  rery  slight  degree-,  to  fhc  appearance;  »f  a 
light  coralline> 


46 

spongy,  or  carnous  caries,  &c.  and  we  have  the  deep  and  super 
ficial.     But,  as  the  cure  of  these  is  to  be  conducted  on  the 
same  principles  in  all  of  them,  and  as  they  are  most  proba- 
bly different  degrees  of  the  same  complaint,  it  will  be  more 
useful  to  divide  them  into  those  which  affect  bones  lying 
deeply,  and  those  which  affect  the  more  superficial  bones  ; 
because  these  different  cases  are  attended  with  very  different 
circumstances  and  symptoms.     The  first  is  preceded  by  an 
abscess,  which  forms  generally  with  much   pain,   runs  its 
course  slowly,  and  does  not  burst  for  a  considerable  time. 
When  it  does  open,  its  sides  do  not  ulcerate,  at  least  univer- 
sally, but  a  sinus  remains,  the  mouth,  or  exposed  part  of 
which  only,  assumes  the  ulcerative  action.     The  second  is 
more  rarely  preceded  by  any  abscess,  but  is  either  coeval 
with  the  ulcer  of  soft  parts,  (both  being  produced  by  me- 
chanical violence)  or  it  succeeds  the  ulcer,  and  is  caused  by 
it.     This  ulcer  belongs  to  the  third  genus,  and  will  be  after- 
wards described. 

In  treating  of  the  cure  of  caries,  the  first  thing  is,  to  de- 
termine by  what  means  the  disease  of  the  bone  may  be  re- 
moved ;  and,  secondly,  what  modification  our  treatment  must 
undergo,  in  consequence  of  the  caries  belonging  to  the 
first  or  second  species.  From  the  very  earliest  periods,  we 
find  the  application  of  stimulating  and  corrosive  remedies 
recommended  in  this  disease.  The  actual  cautery,  euphor- 
bium,  mineral  acids,  scalding  oil,  the  essential  oils,  and  warm 
balsams,  have  been  universally  employed,  and  frequently  al- 
ternated with  rasping  and  perforating  the  bone.  This  pro- 
ceeded from  observing,  that,  on  the  one  hand,  mild  applica 
tions  had  no  effect,  and,  on  the  other,  that  the  natural  slow- 
ness of  exfoliation  was  overcome  by  the  use  of  these  more 
powerful  remedies.  A  caries  of  a  bone  is  correspondent  to 
a  mortification  of  a  soft  part ;  and,  therefore,  it  is  impossible 


17 

to  restore  the  diseased  part  to  health,  or  lite.  Our  chief  ob- 
ject, then,  must  be  to  prevent  the  disease  from  spreading, 
and  to  procure  a  speedy  separation  of  the  dead  portion. 
The  first  is  much  less  under  our  power  than  the  second  ;  for, 
it  is  most  probable,  that,  in  the  majority  of  instances,  al 
least  of  those  of  a  simple  nature,  the  disease,  from  the  first, 
extends  a  certain  length,  affecting  a  portion  of  the  bone,  and 
that  it  afterwards  makes  very  little  progress.  There  is, 
however,  a  specific  disease  which  affects  the  bone  in  com- 
mon with  the  soft  parts.  The  bone  becomes  rough,  and 
suppurates  ;  and  the  soft  parts  have  a  fiery  appearance  : 
This  has  been  called  the  phagedenic  caries.  Cancer,  scro- 
phula,  lues,  and  other  specific  actions,  also  spread  after  they 
are  once  induced.  The  second  object  is  to  be  effected  by 
such  means  as  operate  upon  the  vitality  and  action  of  the 
part,  and  those  which  act  mechanically.  Those  which  tend 
mechanically  to  remove  the  dead  portion,  are  perforations 
down  to  the  sound  part,  which  we  know  has  happened,  by 
the  bleeding  which  ensues  ;  or,  we  may  saw  down  this  length 
Avith  a  trephine.  We  thus,  by  cutting  off  the  communica- 
tion of  part  of  the  diseased  surface  with  the  adjacent  parts, 
kill  it  completely,  sooner  than  could  otherwise  happen,  and 
likewise  stimulate  the  parts  below  to  assume  the  ulcerative 
action,  and  throw  it  off.  We  may  also  sometimes  be  able  to 
turn  out  these  portions  with  a  levator.  Those  which  act 
more  exclusively,  by  affecting  the  action  of  the  part,  are  sti- 
mulating applications  ;  such  as  heat,  acids,  &c.  The  actual 
cautery  is  so  terrifying  to  the  patient,  that  it  is  now  laid 
aside  ;  and  it  is  likewise  liable  to  this  objection,  that  it  may, 
by  its  operation  on  the  neighbouring  parts  of  the  bone,  pro- 
duce disease  in  them.  The  potential  cautery  is  more  use- 
ful, and  may  frequently  be  employed  with  advantage,  either 
in  a  solid  form,  as  to  callus,  &c.  or  dissolved  in  water,  and 


43 

applied  with  a  pencil.*  M.  Sue,  in  his  notes  to  Ravaton's 
Practique,  ike.  recommends  l'eau  mercurielle,  or  solution 
of  mercury,  in  nitrous  acid.  By  these  means,  the  sound 
part  below  assumes  the  ulcerative  action,  its  connexion  with 
the  diseased  portion  is  then  destroyed,  and  reparation  takes 
place.  The  ulcer  of  the  bone  is  red,  and  its  surface  cover- 
ed with  innumerable  granulations,  which  rise  up  to  the  level 
of  the  surrounding  parts,  after  which  a  cicatrice  is  formed. 
These  granulations  in  the  bone  are  absorbed,  and  others  more 
perfect  are  deposited  in  their  place,  until  at  last  they  be- 
come completely  osseous.f 

The  next  point  which  merits  our  attention,  is  the  situation 
of  the  bone,  and  the  circumstances  which  attend  the  caries. 
When  superficial,  a  fungous  ulcer  is  produced,  and  the  mo- 
dification which  this  situation  requires  in  the  application  of 
the  general  plan  will  come  afterwards  to  be  attended  to  ; 
the  modification  in  the  treatment  which  is  required  in  sinuses 
has  been  mentioned  above.  It  may  here  only  be  remarked, 
.  that,  where  the  sinuses  are  superficial,  they  may  be  laid  open, 
which  will  induce  the  ulcerative  action  in  their  course,  and 
allow  us  to  apply  the  proper  remedies  to  the  bone  ;  but 
where  they  run  deep,  we  must  either  allow  the  disease  to 
run  its  natural  progress,  and  treat  the  constitution  according 


s  If  we  use  the  solution,  we  must,  if  the  bone  be  very  porous,  or  spongy,  apply 
only  a  little  at  once,  otherwise  it  may  sink  down,  and  injure  a  part  which  we  do 
not  wish  to  act  on. 

f  There  is  a  curious  case  of  cariesj  which  is  frequently  met  with  :  The  diseased 
part,  instead  of  being  cast  off,  is  surrounded  by  a  covering  of  new  bone,  (except  ai 
one  portion,  where  a  sinus  and  ulcer  is  formed  in  the  soft  parts)  and  may  be  fell 
rattling  within  it.  In  this  case,  there  is  necessarily  a  permanent  enlargement  of 
the  part,  from  Use  additional  bony  matter  ;  and  this,  together  with  the  sinous 
openings,  and  the  internal  caries,  being  felt  with  the  probe,  form  the  character  of 
the  disease,  which  has  been  called  necrosis,  a  term  which  formerly  implied  merely 
mortification.  The  cure  of  this  complaint  is  to  be  accomplished  by  extracting  the 
diseased  part,  when  it  beeomes  loose,  if  the  opening  in  the  case  be  sufficiently 
large ;  if  not,  it  is  to  be  enlarged  with  the  trephine,  &c.  See  the  works  of  Ruysch. 
Desault,  &c. :  and.  more  lately,  the  publication  of  Mr.  Rus'sel. 


49 

to  the  effects  produced,  or,  by  means  of  a  canula,  convey  a 
piece  of  caustic  to  the  diseased  part,  in  the  same  way  as  we 
treat  obstinate  strictures  of  the  urethra,  &c.  When,  with 
the  probe,  we  feel  the  bone  loose,  we  may  assist  its  exit  with 
the  forceps,  or  by  enlarging  part  of  the  sinus,  according  to 
circumstances. 

When  these  sinuses  communicate  with  joints,  uid  depend 
upon  diseased  cartilages,  tendons,  or  articulating  surfaces  of 
the  bones,  we  can  do  very  little  in  the  way  of  curing  them 
by  injections  or  incisions  ;  because  we  cannot  thus  remove 
the  disease  of  the  joint,  but  may  increase  it.  Issues  placed 
over  the  joint,  with  rest,  cleanliness,  and  good  diet,  country 
air,  Sec.  are  the  remedies  chiefly  to  be  employed  in  these 
cases  ;  or,  if  hectic  be  induced,  and  these  remedies  fail,  we 
must  remove  the  diseased  part,  if  this,  on  account  of  its  si- 
tuation, be  practicable.  When,  however,  these  sinuses  are 
superficial,  and  depend  upon  tendons  not  immediately  con- 
nected with  the  articulation,  it  may  be  useful  to  lay  them 
open,  and  treat  the  disease  of  the  tendons  with  caustic,  like 
a  caries  of  a  bone,  or  with  escharotics,  and  stimulating  ap- 
plications. 

The  fourth  species  of  sinuses,  are  those  where  a  specific 
action  exists,*  and  prevents  the  healthy  ulcerative  action 
from  forming.  Of  this  kind  is  the  scrophulous  sinus,  which 
is  generally  accompanied  with  a  caries  bone,  or  diseased 
cartilage,  and,  therefore,  is  a  complicated  sinus.f  This  is 
distinguished,  where  the  bone  is  diseased,  by  a  shining  or 
polished  red  skin,  like  a  cicatrix,  surrounding  the  fungus 
papilla  at  the  orifice  of  the  sinus,  or  the  scrophulous-looking 
sore  which  exists  there.     When  no  caries  bone  exists,  we 


*  These  sinuses  cannot  be  considered  in  this  dissertation, 
f  This  may  sometimes  be  produced  by  the  formation  of  an  abscess,  without  any 
evident  cause;  but  at  other  times  it  is  produced  by  wounds,  &c.  in  schrophulous 

habits.- 


$0 

have  no  papilla,  but  only  the  diseased  ulcer  at  the  orifice. 
In  both  cases,  there  are  generally  the  marks  of  a  scrophulous 
habit.  In  the  first  case,  Ave  are  to  treat  the  sinus  as  if  it 
were  of  the  third  species.  In  the  second  case,  we  are  to 
treat  it  as  if  of  the  second,  conjoining  the  proper  remedies 
internally,  as  will  be  mentioned  in  considering  the  cure  of 
scrophulous  action.  These  sinuses,  although  healed,  have  a 
tendency  to  break  out  again,  especially  in  the  spring  or  sum- 
mer. 

The  effects  of  the  suppurative  action  upon  the  constitu- 
tion, may  be  divided  into  those  which  are  dependent  upon 
the  formation  of  the  action,  such  as  coldness,  listlessness, 
.^c.  which  are  common  to  all  new  actions  ;  and  those  which 
are  peculiar  to  the  action  when  fully  formed.  The  first  set 
requires  no  particular  treatment,  with  an  immediate  refer- 
ence to  their  removal ;  but  their  presence  indicates  the  ne- 
cessity of  changing  our  method  of  cure,  if  we  have  not  alrea- 
dy done  so.  In  conjunction  with  proper  local  applications, 
we  must  give  light  nourishing  diet,  with  or  without  wine,  ac- 
cording to  the  extent  of  the  action  and  the  weakness  of  the 
patient.  Rest,  and  general  warmth,  are  also  necessary ; 
but  the  heat  ought  not  to  be  carried  so  far  as  to  produce  any 
considerable  sensation,  or  sweating.  Diaphoretics  have  been 
recommended  ;*  but  there  does  not  appear  to  be  any  neces- 
sity for  their  exhibition  ;  because  the  coldness, .  and  other 
symptoms  winch  we  intend  to  relieve,  depend  upon  the  state 
of  the  local  action,  and  are  only  to  be  removed  by  fully 
forming  this  action.  Heat  will  not  cure  this  coldness,  or 
shivering,  when  the  action  which  causes  it  is  extensive  ;  but, 
on  the  contrary,  will  frequently  increase  it,  by  accelerating 


:  Mr.  Hunter  supposes  that  these  are  useful,  "  because  the)'  endeavour  to  kee,i 
up  an  universal  harmony,  by  patting  the  skin  in  <rood  humour,  which  quiets  every 
v  mpathising  part,  and  by  counteracting  the  effects  of  irritabi!iiy."  P.  281. 


51 

the  formative  process.  The  immediate  effects,  then,  or  the 
primary  symptoms  of  suppuration,  require  no  particular 
treatment,  with  a  view  to  their  own  removal,  but  are  to  be 
attended  to  as  marks  which  point  out  the  necessity  of  a 
change  of  treatment,  with  a  view  to  keep  up  the  action  which 
induces  them,  and  to  prevent  it  from  producing  bad  conse- 
quences afterwards  to  the  constitution.  Sometimes,  indeed, 
in  delicate  people,  suppuration  at  this  period  produces  hys- 
terical symptoms,  such  as  languor,  flatulence,  or  sometimes 
starting,  tremors,  and  hysteric  paroxysms,  more  or  less  dis- 
tinct. The  slighter  affections  of  this  kind  may  be  frequently 
removed  by  a  little  warm  wine  and  water ;  the  more  severe, 
by  anodynes,  conjoined  with  aromatic  waters. 

The  second  set  of  symptoms,  or  effects,  are  those  which 
have  been  already  described  under  the  name  of  hectic,  the 
production  of  which  has  formerly  been  explained.  This  ac- 
tion, when  slight,  has  been  called  weakness,  and  has  been 
considered  as  dependent  upon  the  quantity  of  the  discharge; 
but,  for  the  reasons  formerly  mentioned,  this  cannot  be  ad- 
mitted. The  cure  of  this  state  is  to  be  attempted,  by  les- 
sening the  local  action,  at  the  same  time  that  we  give  soups, 
and  other  articles  of  nourishing  diet,  with  a  moderate  pro- 
portion of  wine,  if  this  do  not  quicken  the  pulse,  &nd  pro- 
duce heat  of  the  skin.  Anodynes  in  the  evening,  by  procur- 
ing rest,  will  also  be  useful ;  but  none  of  these  remedies  will 
produce  their  proper  effect,  unless  the  patient  respire  a  pure 
air.  Bark  is  considered  as  useful  in  these  case?  ;  but,  unless 
good  diet  be  conjoined,  it  is  not  of  much  benefit.  If,  how- 
ever, we  give  the  means  of  increasing  the  quantity  of  vital 
power,  bark,  by  inducing  an  action  more  nearly  resembling 
the  natural  one,  will  be  serviceable;  but,  fur  this  purpose, 
it  must  be  exhibited  in  full  doses.  It  is  from  giving  this  me- 
dicine too  sparingly,  and  in  cases  wher<;  other  caused,  tend- 
ing to  counteract  its  effects,  such  as  poor  diet,  bad  air,  &c- 

ror.  n.  g 


52 

are  allowed  to  remain  and  operate,  that  bark  has  been  brought 
into  disrepute. 

When  the  general  action  is  very  considerable,  then  the 
exquisite  hectic  is  induced,  and  the  situation  of  the  patient 
becomes  alarming.  When  the  local  action  is  simply  the  sup- 
purative or  ulcerative  action,  we  may  consider  that  the  ge- 
neral disease  is  also  simple,  and  are  to  attempt  the  cure  by 
the  remedies  which  have  been  just  now  mentioned.  In  con- 
junction with  such  local  applications  as  tend  to  check  the 
local  action,  we  must  have  recourse  to  all  those  means  which 
tend  to  strengthen  or  renew  the  natural  action  of  the  system 
in  general ;  for  which  purpose,  we  must  attend,  in  the  first 
place,  to  all  the  particular  functions,  or  individual  parts ;  and, 
in  the  second,  to  the  whole  in  the  aggregate.  Under  the  se- 
cond head  are  included  bark  and  wine,  with  moderate  exer- 
cise,* and  proper  diet ;  in  the  choice  of  which,  we  must  be 
directed  by  the  nourishment  which  is  yielded,  and  by  the 
capability  of  digesting  the  articles  which  we  employ.  In 
general,  milk,  soups,  and  jellies,  answer  best.  Under  the 
first  head  are  included  such  remedies  as  tend  to  promote 
digestion,  such  as  steel,  bitters,  mineral  acids,  &c.  although 
in  general  the  bark  will  supersede  their  use.  The  state  ot 
the  bowels  must  also  be  attended  to,  avoiding  costiveness  on 
the  one  hand,  and  diarrhoea  on  the  other.  The  secretion  of 
the  skin  must  also  be  regulated,  stopping  the  colliquative 
sweating,  if  possible,  by  getting  up  for  some  time  when  it. 
Commences. f  Lessening  the  quantity  of  bed-clothes,  for  a 
few  minutes,  will  also  sometimes  interrupt  it ;  but  when  it 


*  Exercise  may  be  used  either  on  foot,  or  on  horseback,  or  in  a  carriage;  and 
its  degree  must  be  regulated  by  the  strength.  There  are  few  patients  who  cannot 
boar  moderate  exercise  (were  it  no  more  than  walking  half  a  minute  in  a  garden,) 
and  who  will  not  be  the  better  of  this. 

f  Acids  are  supposed  to  check  it;  but  {hey  can  only  act  by  increasing  the 
strength  in  a  secondary  way. 


53 

has  continued  long,  it  can  only  be  checked  by  removing  the 
diseased  action.*  A  full  dose  of  the  bark  given  before  the 
accession  of  the  sweat,  may  sometimes,  by  influencing  the 
morbid  action,  prevent  the  discharge.  The  respiration  must 
in  particular  be  attended  to ;  for,  by  breathing  country  and 
pure  air,  the  action  of  respiration  is  more  fully  performed, 
and,  consequently,  the  source  of  vitality  is  increased,  and  the 
effects  of  our  other  remedies  are  increased.  The  impor- 
tance of  a  change  of  air  can  only  be  known  by  those  who 
have  observed  how  fast  patients  have  recovered  from  opera- 
tions when  removed  to  the  country,  and  clean  lodgings,  with 
well-aired  beds,  although  before  this  they  were  daily  sinking. 
Indeed  no  capital  operation,  which  is  likely  to  induce  the 
suppurative  action,  ought  to  be  performed,  where  cleanliness, 
and  a  free  circulation  of  air,  free  from  fetor,  cannot  be  pro- 
cured. 

It  is  not  yet  discovered  that  any  remedy  has  a  specific 
power  of  removing  the  hectic,  or  diseased  formative  action, 
more  than  the  local  purulent  one  ;f  and,  therefore,  we  are 
obliged  solely  to  trust  to  these  already  mentioned,  which 
have  a  natural  tendency  to  increase  the  healthy  action,  or 
induce  one  nearly  similar  to  it,  and  especially  to  a  proper 
local  treatment,  by  which  we  remove  the  exciting  cause. 

When  these  remedies  fail,  and  the  disease  seems  to  conti- 
nue, or  increase,  in  spite  both  of  general  and  local  remedies, 
then  we  must,  if  it  be  practicable,  remove  the  diseased  part 
by  an  operation ;  and,  in  doing  so,  we  must  remember,  that 
delay  beyond  a  certain  period  is  dangerous  ;  because  the  ge- 
neral action  becomes  so  rooted,  and  the  strength  so  reduced, 


*  Sweating  is  perhaps  to  the  general  hectic  action  what  the  suppuration  is  to 
the  local  one;  and,  therefore,  can  only  be  stopped  by  influencing  this  action. 

t  A  diet  solely  animal  lias  been  proposed  in  that  peculiar  species  of  hectic  which 
Accompanies  diabetes ;  but  whetta/  it  would  be  equally  useful  ia  other  species  ie- 
;iiaios  to  bn  determined. 


54 

that  recovery  cannot  take  place.  Operating  in  these  cir- 
cumstances, therefore,  can  only  hasten  death.  The  wound 
will  not  unite  nor  heal,  and  the  general  action  will  continue 
unabated. 

When  the  local  action  is  specific,  the  general  one  is  also 
different  from  the  simple  hectic  ;  and,  therefore  the  reme- 
dies which  are  useful  in  simple  hectic  will  not  be  of  equal 
advantage  in  these  cases,  unless  a  specific  remedy  be  con- 
joined, as,  for  instance,  mercury  prudently  exhibited  in  the 
venereal  hectic,  dependent  upon  a  neglected  local  complaint. 
The  most  frequent  instance  of  specific  hectic  is  the  scrophu- 
Ious ;  for  the  cure  of  which  we  possess  no  remedy  which 
acts  with  certainty.  Whenever,  therefore,  the  local  com- 
plaint cannot  be  cured,  and  the  hectic  increases,  we  must,  if 
possible,  remove  the  diseased  part  ;*  after  which,  the  gene- 
ral action,  notwithstanding  its  specific  nature,  most  commonly 
declines  ;  but  the  constitution  still  remains,  as  formerly, 
scrophulous,  or  even  more  so  than  before.  That  this  is  the 
case,  would  appear  from  the  following  fact :  If  a  person 
slightly  scrophulous,  although  originally  sprung  from  a  scro- 
phulous stock,  or  in  whom  the  constitutional  disease  seems 
to  be  disappearing,  in  consequence  of  intermarriages,  &c. 
has,  by  means  of  a  local  injury  done  to  a  joint,  Sec.  the  scro- 
phulous action  excited,  and  consequent  hectic,  that  person 
will,  after  cure,  have  the  tendency  to  scrophula  stronger  in 
him  than  formerly;  and  the  disease  will  even  frequently  be 
communicated  to  his  children  with  its  original  violence. 


*  When  this  disease  attacks  the  lungs,  as  it  too  frequently  does,  then,  until  a 
specific  remedy  for  scrophula  be  discovered,  no  cure  can  be  obtained.  Simple  ulce- 
ration, or  suppuration  of  the  lungs,  however,  and  consequent  hectic,  may  be  cured, 
though  not  in  every  instance. 


DO 


Of  the  Treatment  of  the  Ulcerative  Action. 

Suppuration  is  a  natural  termination  of  inflammation; 
and  the  ulcerative  action  is  invariably  induced  by  the  sup- 
purative, unless  this  remain  chronic.  The  ulcerative  action 
is  to  be  considered  as  in  part  a  restoration  of  the  natural  one  ; 
for  we  find  that  it  produces  a  restoration  of  the  structure, 
granulations  being  formed  by  the  vessels  which  formerly  sup- 
plied the  organic  particles,  whilst  the  interstitial  vessels  still 
yield  a  morbid  fluid,  called  pus  ;  but  this  they  cease  to  do, 
whenever  they  again  are  placed  in  the  natural  situation ;  that 
is  to  say,  whenever  they  become  covered  with  the  granula- 
tions, or  are  rendered  interstitial.  In  proportion,  then,  as 
granulations  are  formed,  a  certain  number  of  vessels  are  ren- 
dered interstitial,  so  that  the  discharge  gradually  diminishes, 
until  at  last  it  ceases ;  for,  when  we  come  to  the  formation 
of  a  cuticle,  we  have  very  few  interstitial  vessels  left,  the 
skin  having  naturally  few.  At  this  time,  the  one  set  of  ves- 
sels having  completed  their  action,  and  the  part  being  re- 
stored, the  other  also  resume  their  action,  and  a  thin  exhalent 
fluid  is  thrown  out  by  the  new  cuticle,  which  keeps  it  soft 
and  moist,  and  which  is  the  natural  insensible  perspiration. 
The  action  of  the  two  sets  of  vessels,  then,  is  dependent  on 
each  other ;  and,  whenever  one  is  diseased,  the  other  be- 
comes also  more  or  less  so. 


GENUS  I. 

Of  the  Healthy  Ulcer. 

From  these  remarks,  as  well  as  from  those  which  were 
formerly  made,  it  will  appear,  that  a  healthy  ulcer  Iras  a  na> 


56 

Jural  tendency  to  heal,  and  that  we  ought  only  to  be  care- 
ful not  to  interrupt  the  natural  progress,  nor  allow  the  action 
to  flag. 

In  this  genus  of  ulcers,  the  bottom  of  the  sore  seems  to 
be  paved  with  a  number  of  small  fleshy  points,  with  minute 
interstices  betwixt  them,  or  surrounding  their  bases.  These 
are  of  a  red  colour,  with  a  slight  shade  of  the  purple,  and 
are  wet  with  a  yellowish  fluid,  which  is  called  pus  ;  but 
which  must  of  necessity  differ  from  the  fluid  yielded  by 
suppuration.  This  separates  freely  from  the  surface,  when 
it  is  wiped  or  touched  with  a  sponge,  and  then  the  granula- 
tions may  be  distinctly  observed.*"  The  margins  are 
smooth,  thin,  and  a  very  little  rounded,  that  is  to  say,  are  al- 
most imperceptibly  raised  above  the  granulations,  a  circum- 
stance which  is  essential  to  this  ulcer,  because,  were  they 
both  on  the  same  level,  it  would  show,  that  the  cicatrizing 
process  did  not  go  on  properly ;  for,  whenever  the  granula- 
tions rise  to  the  level  of  the  surface,  they  ought  instantly  to 
form  skin.  This  cicatrix,  which  extends  gradually  from  the 
circumference  to  the  centre,  is  of  a  pale  red  colour ;  but 
the  integuments  immediately  beyond  it  are  white,  and  of  the 
natural  appearance.  Sometimes,  from  a  slight  deviation  or 
imperfection,  one  spot  of  the  disk  rises  to  the  level  sooner 
than  the  rest ;  but,  in  this  case,  it  immediately  skins,  and 
the  cicatrix  extends  from  this  in  the  same  way  as  from  the 
circumference,  until  they  both  meet.  The  sore  is  free  from 
pain,  the  only  sensation  being  a  slight  degree  of  smarting,  or 
itchiness. 

The  treatment  of  this  ulcer  is  very  simple ;  for,  in  most 
cases,  it  is  only  essentially  necessary  that  we  prevent  the 
operation  of  hurtful  causes.     We  defend  the  part,  by  cover- 

*  Whenever  the  discharge  does  not  separate  completely  from  the  surface,  wheu 
it  is  wiped,  but  part  of  it  remains  lite  a  film,  or  jelly,  betwixt  the  granulation", 
or  on  particular  spot?,  we  may  be  sure  that  the  action  is  not  healthy. 


57 

ing  it  with  a  soft  pledget  of  lint,  and  keep  it  warm.  When 
the  cicatrization  has  commenced,  it  may  be  assisted  by  using 
an  ointment  containing  any  harmless  powder,  in  such  a  pro- 
portion as  to  form  a  paste  or  scab  upon  the  part,*  by  which 
we  afford  an  artificial  covering,  which  remains  in  close  con- 
tact with  the  granulations  ;  and,  by  thus  bringing  them 
nearly  into  the  same  circumstances  as  when  skin  is  formed, 
the  cicatrizing  action  is  accelerated.  The  same  effect  is 
sometimes  produced,  by  allowing  the  pus  to  form  a  scab  over 
superficial  sores,  by  exposing  them  to  the  air,  without  any 
covering. 

Dry  lint  is  a  very  useful  application  ;  but,  as  it  is  apt  to 
stick  to  the  granulations,  and  tear  them,  when  tender,  it 
ought  always  to  be  well  moistened  before  removal,  which 
should  be  attempted  slowly. 

Mild  ointments,  such  as  the  simple  cerate,  are  frequently 
employed  ;  but  they  must  be  free  from  all  rancidity,  other- 
wise they  fret  the  skin,  or  injure  the  sore.  In  general,  they 
are  less  useful  than  dry  lint.  When  we  do  employ  them, 
they  ought  to  be  applied  only  to  the  granulations  and  cica- 
trix; and  not  to  the  sound  skin.  More  frequently  we  use 
these  ointments  spread  on  a  pledget  of  linen,  to  keep  the 
dry  lint  on  the  sore. 

Poultices  are  also  recommended  in  these  cases  ;  but  they 
possess  no  peculiar  advantage,  and  are  apt  to  make  the  part 
feeble,  and  more  likely  to  break  out  asain. 

Moderate  pressure,  by  keeping  up  the  action,  is  generally 
of  service;  but  it  is  still  more  necessary  when  the  action 
begins  to  flag,  or  becomes  stationary.  In  this  case,  a  com- 
press ought  to  be  placed  over  the  sore,  and  the  whole  ;m  m- 


*  Simple  ointment,  rubbsd  up  with  a  fourth  part,  of  its  weight  of  finely  le- 
vigated calamine,  or  flowers  of  zinc,  makes  a  useful  application.  Mr.  Bell  re 
commends,  among  other  remedies,  a  saturnine  ointment;  b:it,  if  this  produces 
any  specific  operation,  it  must  be  a  hurtful  one.  injuring  the  action 


38 

ber  rolled  firmly  round  with  a  cotton  bandage;  or,  what  will 
be  still  more  useful,  the  part  should  be  encircled  with  strips, 
spread  with  adhesive  plaster,  in  the  way  which  will  after- 
wards be  mentioned.  Pressure  acts  by  taking  away  the 
condition  of  vacuity  ;  it  forms  an  artificial  covering  and  in- 
terstices for  the  superficial  granulations,  by  which  the  natu- 
rar process  of  forming  granulations  and  skin  is  greatly  assist- 
ed. The  parts  are,  in  this  way,  not  only  more  quickly 
formed,  but  also  in  greater  perfection ;  and  their  powers  of 
action  are  greater.  The  cure  is  therefore  more  permanent, 
and  the  part  is  not  so  apt  to  die,  or  ulcerate  again,  as  when 
healed  with  simple  dressings. 

This  practice,  which  is  useful  in  ulcers  which  from  the 
first  are  healthy,  is  still  more  necessary  in  curing  those  which 
were  formerly  diseased,  but  have  now  become  healthy  ;  be- 
cause, in  them,  the  action  is  still  more  apt  to  flag. 

The  healing  of  large  healthy  ulcers  which  succeed  to 
wounds,  &c.  will  also  be  much  hastened,  if  we  artificially  di- 
minish the  size  of  the  cavity,  and  procure  contact.  When- 
ever one  part  can  be  brought  in  contact  with  another,  it 
ought  to  be  done,  if  Ihe  figure  and  functions  of  the  part- be 
not  thereby  injured,  or  if  pain  be  not  produced  by  doing  so. 

The  older  authors,  from  a  mistaken  theory,  never  allowed 
the  action  to  proceed  uninterrupted,  or  never  co  operated 
with  it  in  a  rational  manner.  In  every  ulcer,  it  was  neces- 
sary, first,  to  digest,  or  suppurate  it,  which  was  done  with 
turpentine,  or  basilicon ;  next  it  was  to  be  deterged  with  tur- 
pentine, mixed  with  yolk  of  eggs,  or  by  the  red  precipitate  ; 
then  it  was  to  be  incarned  by  sarcotics,  such  as  tincture  of 
myrrh  and  aloes,  balsam  of  Peru,  frankincense,  &c.  ;  lastly, 
the  surface  was  to  be  dried  into  a  callus,  with  dragon's  blood, 
white-lead,  chalk,  &c.  These  plans  have,  however,  been 
long  laid  aside  ;  but  some  practitioners  still  advise  the  use  of 
styptics  and  spirit  of  wine  to  produce  a  cicatrix  ;  they  for- 


59 

get,  however,  that  skin  is  formed  by  a  different  process  than 
corrugation. 

The  diet  ought  to  be  good,  in  all  cases  of  ulcers  ;  but 
spirituous  liquors,  and  the  irregularities  of  life,  must  be 
avoided. 

In  ulcers  of  the  legs,  if  pressure  be  employed,  rest  is  not 
absolutely  requisite  ;  but,  if  this  be  not  used,  no  cure  can  be 
obtained,  if  the  patient  walk  about.  Even  if  the  adhesive 
plaster  be  applied,  Ave  ought  not  to  allow  of  so  much  motion 
as  to  produce  fatigue,  or  any  uneasiness  in  the  sore. 

The  treatment,  then,  of  this  genus  of  ulcers,  may  be  com- 
prised in  two  aphorisms. 

First.  When  the  action  is,  from  the  first,  healthy  and  vi- 
gorous, and  is  continuing  so,  all  which  is  essentially  neces- 
sary, is  to  defend  the  part,  and  prevent  the  operation  of  any 
cause  which  might  injure  the  action,  such  as  cold,  too  much 
heat,  mechanical  irritation,  &c.  This  may  be  done,  by  ap- 
plying a  bit  of  dry  lint,  or  a  rag  spread  with  simple  ointment, 
and  wrapping  the  limb  round  with  a  flannel  roller.  But,  if  the 
action  begins  to  flag,  as  it  often  does  in  large  ulcers,  or  if  the 
process  become  stationary,  we  must  then  indispensably  have 
recourse  to  gentle  pressure. 

Second.  When  the  action  has,  at  any  one  period,  been 
diseased,  or  too  low,  but  has  been  restored  to  a  proper  state* 
we  must  of  necessity  continue  gentle  pressure,  and  treat  the 
sore  as  if  the  action  were  stationary,  although  it  may  not  be 
so. 


VOL.    II. 


m 

GENUS  II 
Of  the  Indolent  Ulcer. 

In  this  genus,  the  action  is  diminished,  and,  consequently, 
rendered  imperfect  and  diseased. 

Indolent  ulcers,  like  those  of  the  next  genus,  are  divisible 
nito  two  species :  First,  that  in  which  both  parts  of  the  ul- 
cerative action,  namely,  the  granulating  and  purulent,  are 
equally  diseased,  and  equally  imperfectly  performed :  Se- 
cond, that  in  which  one  part  is  more  affected  than  another.* 

The  first  species  is  distinguished  by  the  following  symp- 
toms, which  appear  in  greater  or  less  degrees,  according  to 
the  diminution  and  imperfection  of  the  action. 

The  granulations  are  pale  and  imperfectly  formed,  par- 
taking less  of  the  firmness  and  organization  of  the  healthy 
Qeshy  granulations  in  proportion  to  the  affection  of  the  ac- 
tion. They  are  obtuse,  and  scarcely  at  all  elevated ;  and, 
therefore  the  surface  loses  its  dotted,  or  red  pointed  appear- 
ance. The  discharge  is  thin,  and  of  a  whitish  colour,  at  the 
same  time  that  we  frequently  observe  isolated  spots  of  lymph 
interwoven  here  and  there  with  the  imperfect  granulations. 
Although  these  granulations  are  said  not  to  be  elevated,  yet 
the  surface  often  exhibits  a  species  of  fungus ;  but  the  indi- 
vidual granulations  are  not  elevated,  or  pointed.  This  fun- 
gus never  rises  higher  than  the  twentieth  part  of  an  inch 
above  the  level  of  the  surrounding  skin,f  and  often  appears 


*  The  circumstance  of  one  part  of  an  ulcer  being  more  affected  than  another,. 
will  be  more  fully  noticed  in  considering  the  next  genus,  in  which  it  is  of  more 
practical  consequence.  Ulcers  generally  belong  to  this  species,  before  they  as- 
sume the  characters  of  the  second  (for  they  frequently  change  from  one  species,  or 
genus  to  another;  in  which  case,  the  treatment  must  also  be  changed.) 

f  The  cause  why  these  granulations  rise,  even  this  trifling  height,  above  the 
level  of  the  skin,  is  the  indolence  of  the  action,  which  prevents  a  cuticlefrom.be 
ing  formed  in  due  time- 


(51 

m\\y  at  particular  parts  of  the  surface.     It  is  pale,  and  seme 
what  of  a  gelatinous  appearance.     The  pain  is  trifling. 

In  more  advanced  cases,  the  whole  disk  is  covered  with  a 
thin  layer  of  lymphatic  substance,  which  adheres  firmly,  and 
gives  the  idea  of  a  thin  pellicle  being  thrown  over  the  granu- 
lations, which  are  seen  imperfectly  and  irregularly  through 
it.  The  discharge  is  generally  thin,  like  serum,  and  con- 
siderable.* The  edges  are  hard  and  tumefied,  sometimes 
of  a  light  purple  colour,  at  other  times  white.f  The  sur- 
rounding integuments  are  also  hard  and  thickened,  at  least 
in  old  ulcers,  and  the  veins  are  generally  more  or  less  vari- 
cose. 

These  appearances  vary  in  -degree  from  the  soft  pale  sur 
face,  and  thin  whitish  purulent  discharge,  with  slightly  thick 
€ned  edges,  to  the  state  now  described.  The  pain,  when 
compared  to  the  size  of  the  ulcer,  is  not  considerable. 

This  genus  may  occur,  in  a  slight  degree,  in  recent  sores. 
from  neglect,  &c.  ;  but  it  is  chiefly  after  ulcers  have  been 
of  long  standing,  that  they  assume  these  appearances  in  the 
greatest  degree.  They  may  then  be  said  to  have  become 
chronic  or  habitual ;  and,  in  many  instances,  it  is  absolutely 
impossible  to  restore  the  action  to  its  natural  state,  and  pro- 
duce recovery.  J 

The  second  species  is  distinguished  by  the  paleness  and 
imperfection  of  the  granulations,  whilst  the  discharge  is  tol- 
erably good  ;  but  it  never  can  be  equal  to  that  of  the  healthy 


*  Indolence  of  the  action  does  not  imply  that  the  quantity  of  a  discharge  should 
be  lessened,  but  only  that  its  nature  should  be  changed.  In  this  species,  the  dis- 
charge is  much  the  same  in  quantity  as  in  a  healthy  ulcer  of  the  same  size,  but  its 
perfection  is  greatly  less. 

t  Sometimes  the  granulating  action  and  the  cicatrizing  one  seem  to  be  con- 
founded, the  surface  exhibiting  a  fibrous  fleshy  appearance.  This  I  have  seen  moSL 
frequently  in  the  calf  of  the  leg  ;  but  it  may  occur  in  other  parts. 

\  These  ulcers,  after  long  continuance,  frequently  induce  a  disease  in  the  boner 
or  mnscles  seated  below  them,  as  will  afterwards  be  mentioned, 


62 

ulcer  ;  because,  when  one  part  of  the  action  is  affected,  the 
other  is  also  more  or  less  affected.  This  species  does  not 
require  any  more  particular  observation  or  mark,  because  it 
is  to  be  treated  exactly  as  the  first,  of  which  it  is  often  just 
a  slighter  degree,  or  a  forerunner ;  for  it  is  frequently  the 
first  change  which  takes  place  in  a  healthy  ulcer.  When  it 
becomes  diseased,  it  does  not  continue  long  ;  for  both  parts 
soon  come  to  suffer  in  the  same  proportion  ;  in  which  case, 
the  ulcer  belongs  to  the  first  species.  For  this  reason,  we 
never  find  old  ulcers  belonging  to  this  species. 

Chronic  ulcers  sometimes  induce  a  disease  of  the  bones, 
&c.  below  ;  but,  in  this  case,  they  generally  are  converted 
into  a  different  genus.  They  also  come  naturally,  in  conse- 
quence of  the  great  imperfection  of  their  action,  and  the  con- 
sequent want  of  power,  to  act  beyond  the  due  proportion 
betwixt  action  and  power;  and,  therefore,  most  ulcers  of 
this  genus  come  at  last,  if  neglected,  to  belong  to  the  next. 

The  most  effectual  remedy  for  these  ulcers  is  pressure. 
This  has  been  long  employed,  by  means  of  tight  rollers 
wound  round  the  limb,  or  by  the  laced  stocking.  But,  of 
late,  a  more  effectual  method  has  been  proposed,  namely,  a 
bandage  of  adhesive  plaster,  which  applies  itself  closely  to 
the  surface,  and  produces  a  state  of  artificial  contact  and  co- 
vering. This  has  been  recommended  by  Dr.  Darwin  in  the 
form  of  a  many-tailed  bandage,  and  by  Mr.  Baynton  in  the 
form  of  strips,  wrapped  round  the  limb.  The  following  is 
the  method  of  applying  them  :  A  strip  of  adhesive  plaster, 
about  an  inch  broad,  and  so  long  as  to  encircle  the  limb  and 
cross  at  each  end,  is  to  be  warmed,  and  the  middle  of  it  ap- 
plied to  that  part  of  the  limb  which  is  exactly  opposite  to 
the  sore  ;  both  ends  are  now  to  be  brought  forward,  and  one 
of  them  laid  tightly  over  the  under  part  of  the  sore  (if  it  be 
so  large  as  not  to  be  covered  with  one  strip,)  whilst  the  other 
is  brought  firmly  over  this  from  the  opposite  side,  and  dou-^ 


63 

bled  down  upon  it.  The  ends  of  the  strip  thus  fold  over 
each  other  at  the  ulcer.  Another  strip  is  then  to  be  applied 
to  the  part  of  the  sore  contiguous  to  this  which  is  not  yet 
covered,  and  so  on  in  succession,  until  the  whole  be  cover- 
ed. This  is  the  best  way  of  applying  the  strips,  if  the  in- 
teguments be  firm ;  but,  if  they  be  loose  and  yielding,  it  will 
be  useful  to  push  forward  the  loose  skin  from  behind,  with 
the  strips,  as  we  bring  them  forward  ;  and,  instead  of  laying 
down  first  one  end,  and  then  the  other  over  it,  make  the  two 
ends  cross  each  other  at  the  same  time,  and  lay  them  down 
upon  the  skin,  and  not  on  each  other,  the  under  end  covering 
the  lower  part  of  the  sore,  and  the  upper  the  part  next  it. 
The  same  strip,  therefore,  covers  two  portions  of  the  surface, 
whereas,  in  the  first  way,  it  covered  only  one  ;  but,  in  this 
case,  the  strip  must  be  longer,  as  it  must  fairly  cross  the 
ulcer  on  each  side,  and  be  retained  by  sticking  to  the  adja- 
cent skin.  When  the  ulcer  is  deep,  the  strip  will  press  on- 
ly on  the  margins  ;  and,  therefore,  it  will  be  useful  to  fill  up 
the  surface  with  a  fold  of  soft  lint.  A  thin  cotton  roller  is 
now  to  be  wound  firmly  round  the  limb,  begining  at  the  ex- 
tremity, and  continuing  the  bandage  to  the  next  joint  above 
the  sore. 

By  this  contrivance,  we  obtain  a  firm  covering  to  the 
granulations,  and  bring  a  substance  in  contact  with  each 
individual.  We  then  restore,  as  it  were,  the  natural  state 
of  the  parts,  each  granulation  having  a  substance  in  contact 
with  it ;  and  a  slight  interstice  is  left  between  each,  owing 
to  their  pointed  structure.  They  become,  therefore,  similar, 
in  this  respect,  to  the  organic  particles  of  internal  parts  ;  on 
which  account,  healing  goes  on  more  quickly,  and  the  or- 
ganic particles,  or  granulations,  are  deposited  in  greater  per- 
fection, and  with  greater  powers  of  action ;  for  the  unusual 
and  morbid  condition  of  exposure  and  want  of  contact  is 
now  removed.     The  same  circumstances  promote  cicatriza- 


64 

tion,  when  the  "granulations  have  risen  to  a  proper  height. 
This  is  more  evidently  seen  in  the  cure  which  is  effected  of 
the  smaller  ulcers,  by  dusting  them  with  chalk,  &c.  or  dress- 
ing them  with  an  ointment  made  thick  with  some  mild  pow- 
der, by  which  a  scab,  or  covering,  is  formed,  which  operates 
clearly  independent  of  pressure.  Pressure,  applied  with 
this  view,  ought  to  be  moderate  and  permanent,  and  may  be 
used  with  utility  in  almost  every  case  of  solution  of  continui- 
ty, however  healthy  the  action  may  be.  But,  besides  being 
of  use  in  this  way,  pressure  also  produces  a  second  set  of  ef- 
fects, by  mechanically  exciting  action  in  the  part  to  which 
it  is  applied.  Applied  to  the  skin,  it  increases  the  cuticular 
action,  and  the  skin  is  formed  thicker.  Applied  to  a  weak- 
ened part,  it  increases  the  natural  action  of  that  part,  and 
strengthens  it :  This  is  seen  in  the  instance  of  debilitated 
muscles,  &c.  But,  if  the  pressure  be  loo  great,  then  a  mor- 
bid increase  of  action  takes  place,  which  even  goes  the 
length  of  inflammation,  if  the  pressure  be  considerable  ;  and 
this  inflammation  is  either  strong  or  weak,  according  as  the 
pressure  has  operated ;  for,  if  many  vessels  be  obstructed, 
as  is  commonly  the  case,  then  the  power  of  the  part  is  in- 
jured, and  the  action  is  weak ;  or,  the  same  happens  if  pres- 
sure be  applied  in  any  manner  to  a  weak  part,  or  if  the  con- 
stitution be  weak  ;  as,  for  instance,  from  previous  disease. 

Pressure,  applied  to  a  part,  increases  in  particular  the 
functions  of  absorption  and  deposition.  If  moderate,  these 
functions  are  moderately  increased,  and  the  structure  of  the 
part  continues  either  the  same,  or  it  augments  in  size,  as  we 
observe,  in  the  effects  of  walking,  on  the  skin  of  the  feet ; 
hut,  if  the  pressure  be  greater,  then  these  functions  are  mor- 
bidly increased,  the  particles  are  deposited  imperfectly 
formed,  and  are  as  quickly  taken  up.  The  structure  is  there- 
fore destroyed,  and  a  vacuity  formed.  These  effects  are 
produced  more  easily  upon  diseased  than  healthy  structures  : 


65 

because  their  powers  of  acting,  and  sustaining  action,  are 
Jess-     Friction  is  in  this  respect  similar  to  pressure. 

From  these  remarks,  we  may  understand  the  mechanical 
utility  of  pressure  in  the  cure  of  ulcers  ;  for,  when  in  a  pro- 
per degree,  it  causes  the  absorption  and  destruction  of  the 
callous  edges,  or  diseased  substance,  and  likewise  makes,  if 
moderate,  the  diseased  granulations  be  taken  up,  and  more 
healthy  ones  be  formed.  We  may  likewise  perceive,  that, 
if  the  degree  be  too  great,  the  action  will  become  of  an  in- 
flammatory nature,  and  injury  will  be  done.  We  are  there- 
fore frequently  under  the  necessity  of  counteracting  this 
hurtful  effect ;  for,  the  degree  of  pressure  which  is  requisite 
for  answering  the  first  intention  in  old  sores,  or  inducing  ac- 
tion, in  consequence  of  bringing  the  granulations  or  particles 
into  the  natural  state  of  being  in  contact  with  some  body,  or 
covered  by  it,*  is  often  attended  with  such  mechanical  irri- 
tation, that  the  one  effect  would  destroy  the  other,  unless  we 
kept  the  action  within  due  bounds,  by  applying  cold  to  the 
part.  In  healthy  ulcers,  the  pressure  necessary  to  produce 
its  first  set  of  effects,  or  to  accelerate  healing,  by  producing 
contact,  is  so  trifling,  that  no  counteracting  effect  takes 
place  by  the  production  of  the  second  set  of  effects  ;  and, 
therefore,  no  cold  requires  to  be  applied :  But,  in  old  ulcers, 
the  pressure  must  be  greater  ;  and,  therefore,  cold  water 


*  The  degree  of  pressure  necessary  for  producing  this  effect  is  proportioned  t« 
the  susceptibility  of  the  granulations,  or  organic  particles,  for  receiving  the  im- 
pression of  being  in  contact.  When  a  part  is  healthy,  the  mere  circumstance 
of  juxtaposition  is  sufficient  for  this  purpose  ;  and,  in  a  healthy  ulcer,  the  weight 
©f  the  body  applied,  such  as  powdered  chalk,  or  plaster  of  Paris,  or  at  least  the 
gentle  pressure  of  a  stocking,  or  easy  bandage,  is  all  that  is  necessary.  But,  when 
the  action  is  too  low,  and  the  granulations  are  consequently  imperfect,  both  in 
their  structure,  power  of  acting,  and  capability  of  receiving  impressions,  the  con- 
tact, in  order  to  operate,  must  be  nearer,  and  more  complete  ;  or,  in  other  words, 
the  pressure  must  be  greater.  In  these  cases,  bandages  not  only  act  on  the  sur- 
face, but  also  on  the  parts  below,  and,  therefore,  increase  the  degree  of  contact 
«f  the  newly-formed,  organic  particles,  and  thus  strengthen  the  part, 


66 

must  be  constantly  applied  to  the  bandage  orer  the  sore,  by 
means  of  a  sponge.  We  thus  indeed  lessen  the  effects  of 
pressure  on  the  absorbing  system,  and,  therefore,  the  callus 
will  be  longer  of  being  destroyed ;  but  we,  on  the  other  hand, 
prevent  the  action  of  the  granulations  from  being  rendered 
morbid. 

The  good  effects  of  pressure,  applied  in  a  degree  propor- 
tioned to  the  effect  which  we  wish  to  produce,  and  to  the 
state  of  the  sore,  are  so  universal,  that  it  is  unnecessary  to 
give  any  examples  of  its  success  and  utility.  But,  at  the 
same  time,  it  must  be  observed,  that  in  old  ulcers,  and  even 
in  many  of  a  more  recent  date,  which  have  been  much  neg- 
lected, no  application  whatever  will  produce  an  uninterrupt- 
ed cure ;  for,  after  some  time,  it  ceases  to  produce  the  same 
effect  upon  the  action.  The  part  seems,  by  continuance,  to 
be  less  acted  on  by  the  agent ;  the  action  is  less  affected, 
and  slowly  returns  to  its  former  state  of  imperfection.  It  is 
therefore  necessary,  either  that  we  from  time  to  time  increase 
the  power  of  our  application,  or  vary  our  remedies,  when- 
ever the  process  becomes  stationary.  The  latter  is  general- 
ly the  most  effectual  way  ;  and  the  remedies  which  we  al- 
ternate with  the  effects  of  pressure,  are  those  of  what  have 
been  called  the  stimulating  kind  ;  but  which  of  the  indivi- 
duals of  this  division  ought  to  be  employed,  cannot  always 
be  determined,  because  one  succeeds  better  in  a  particular 
instance  than  in  another.  It  would,  however,  be  of  much 
importance,  to  ascertain  which  in  general  operated  most  ef- 
fectually ;  because,  if  we  employ  one  which  does  no  positive 
good,  we  sustain  positive  harm  ;  for  the  action  is  allowed  to 
persevere  in  a  retrograde  process.  I,  therefore,  paid  parti 
cular  attention  to  the  operation  of  these  applications,  in  the 
patients  who  were  under  my  care  in  the  Glasgow  Infirmary. 

Heat  is  found  to  increase  almost  every  action ;  and,  there- 
fore, in  indolent  ulcers,  it  is  sometimes  of  use,  especially  for  a 


67 

days  after  we  begin  the  management  of  the  sore,  as  it  paves 
the  way  for  the  action  of  other  agents,  by  beginning  a  change 
of  the  action.  Poultices  are  the  vehicle  by  which  it  is  most 
frequently  applied,  and  answers,  in  general,  better  than  other 
forms.  Fomentations  are  much  used  by  many  practitioners, 
who  employ  decoctions  of  different  kinds  of  vegetables ;  but 
they  have  no  superiority  over  poultices.  Dry  heat  was 
used  by  M.  Hevin,  who  held  ignited  charcoal  near  the  sore ; 
and  it  is  sometimes  of  use  to  repeat  this  practice  betwixt  each 
dressing. 

Electricity  is  of  little  service  ;  because  it  cannot  be  con- 
stantly employed  ;  and,  therefore,  its  operation  is  only  tem- 
porary. 

It  is  worthy  of  observation,  that  although  this  kind  of  ulcer 
may  be  sometimes  completely  cured  by  the  use  of  heat,  that 
yet  the  action  is  not  so  perfect,  and  consequently  the  struc- 
ture and  power  of  the  part  is  weaker,  than  when  stimulating 
dressings  are  employed.  Exercise,  or  any  other  cause,  is 
therefore  more  apt  to  injure  the  part  afterwards,  and  make  it. 
again  break  out  into  an  ulcer. 

The  red  precipitate,  mixed  with  resinous  ointment,  in  the 
proportion  of  a  drachm  of  the  former  to  an  ounce  of  the  lat- 
ter, is  a  very  useful  dressing  ;  but  the  ung.  hyd.  nit.  mixed 
with  four  times  its  weight  of  hog's  lard,  forms  an  ointment 
which  is  still  more  generally  useful. 

Ten  grains  of  the  cuprum  ammoniatum,  rubbed  up  with 
an  ounce  of  basilicon,  or  simple  ointment,  is  sometimes  use- 
ful, but  cannot  be  depended  on.  The  same  may  be  said  of 
an  ointment  composed  of  an  ounce  of  ung.  simplex,  and  ten 
drops  of  the  oil  of  cloves,  or  of  savin. 

Cloths  dipped  in  the  aqua  zinci  vitriolati,  or  the  solution 
of  cuprum  vitriolatum,  diluted  with  water,  so  as  only  to  smart 
moderately,  are  likewise  of  service,  but  not  so  frequently  as 
weak  solution*  of  the  nitrates  of  silver,   zinc,   copper,  bis- 

VOL.    II.  I 


(53 

muth,  and  many  other  metallic  salts,  such  as  muriate  of  mer- 
cury, &c. 

Solution  of  common  salt,  or  of  nitre,  of  such  a  strength  as 
to  produce  a  moderate  smarting,  are  of  temporary  advantage, 
but  will  not  continue  their  effect  long.  Indeed,  all  solutions 
of  saline  substances,  whether  alkaline  or  metallic,  are  most 
useful  when  applied  only  for  half  an  hour  at  a  time,  when  the 
sore  is  dressing. 

Mixtures  of  Thus,  elemi,  turpentine,  canadine  balsam, 
&c.  with  wax,  or  oil,  have  no  advantage  over  the  common 
ung.  resinosum.* 

The  bile,  either  by  itself,  or  diluted,  or  mixed  with  yolk  of 
eggs,  does  not  seem  to  be  of  much  service. 

Lemon' juice,  or  the  mineral  acids,  particularly  the  nitrous, 
diluted  so  as  to  be  of  equal  strength  with  the  juice,  are  fre- 
quently of  service.f     Port  wine  is  also  an  useful  lotion. 

Infusion  of  Cayenne  pepper,  in  vinegar,  added  to  water,  in 
such  a  quantity  as  to  smart,  forms  also  a  very  useful  appli- 
cation. 

Of  all  these  remedies,  the  ointments  composed  of  the 
nitro-metallic  salts,  particularly  the  mercurial,  are  most  gene- 
rally useful :  And  the  cure  seems  to  be  accelerated,  by  ap- 
plying cloths  dipped  in  weak  solution  of  metallic  salts,  or 
weak  acids,  during  the  intervals  of  dressing.  Whenever 
these  applications  fail,  they  must  be  dropped :  And  those 
which  fail  first,  and  soonest,  seem  to  be  the  watery,  or  fluid 
applications  ;  and,  next  to  these,  the  simple  resinous  oint- 
ments. 


*  An  ointment  composed  of  these  resinous  substances  is  much  recommended  in  the 
Acta  Med.  Berolrn.  Tom.  VII.  p.  58. 

f  These  acids  coagulate  the  pus,  and  thus  afford  an  artificial  covering,  or  film, 
which  remains  in  close  contact  with  the  granulations,  and  thus,  by  producing  the 
natural  circumstance  of  contact  and  covering,  the  effects  of  which  hare  been  al- 
ready mentioned,  as  well  as  by  creating  a  more  vigorous  action  by  their  specific 
action,  they  frequently  briDg  those  sores  into  a  healthy  state. 


69 

These  remedies  generally  produce  their  effect  first  at  the 
margins.  When  this  takes  place  we  must  diminish  the  strength 
of  the  application  at  that  part,  in  proportion  to  the  activity 
of  the  action,  which  is  marked  by  the  redness  and  pointed- 
ness  of  the  granulation,  and  the  cicatrizing  state.  The  cir- 
cumference, and  the  rest  of  the  surface,  must,  in  this  case,  be 
dressed  with  different  strips  of  linen,  spread  with  different 
ointments.  Soft  linen,  spread  with  simple  cerate,  or  dry 
lint,  which  is  preferable,  should  be  applied  to  the  cicatrix, 
and  cicatrizing  granulations,  whilst  a  stimulating  substance. 
is  applying  to  the  rest  of  the  surface. 

When  the  surface  is  obstinately  diseased,  or  the  action 
very  torpid  and  imperfect,  caustic  has  been  applied  ;  but,  al- 
though I  have  often  used  it,  and  even  applied  cloths  dipped 
in  solutions  of  metallic  salts,  so  strong  as  to  form  an  universal 
eschar,  or  slough,  yet  no  benefit  whatever  was  derived ;  for 
we  do  not  thus  change  the  nature  of  the  action,  but  only  re- 
move a  layer  of  the  surface,  and  leave  that  below  in  possession 
of  the  same  mode  of  action  with  the  former.  Caustic  is  more 
useful,  when  applied  to  callus  edges  ;  but  even  these  are  more 
effectually  removed,  by  remedies  which  act  more  permanent- 
ly, and  gradually,  particularly  by  pressure.  The  ancients 
used  to  extirpate  these  with  the  knife,  but  few  will  consent 
to  its  use.  It  is  indeed  more  speedy  and  effectual  than  the 
caustic ;  but,  unless  the  action  be  afterwards  properly  sup- 
ported, it  will  be  of  no  permanent  service- 

The  hard  and  thickened  state  of  the  surrounding  integu- 
ments, in  old  ulcers,  is  best  moderated  by  pressure ;  but  thi* 
must  be  long  continued. 

Varicose  veins  were,  by  the  ancients,  considered  as  canals 
running  into  the  sore,  and  furnishing  the  discharge ;  but, 
when  we  consider  that  these  varices  frequently  occur  with- 
out any  ulceration,  or  discharge,  the  opinion  must  be  aban- 
doned.    In  such  cases  as  occur  along  with  ulceration,  it  witi 


70 

be  more  natural  to  consider  the  affection  of  the  vein  as  & 
disease  dependent  originally  on  the  ulcer,  and  induced  by  it, 
in  the  same  way  as  the  structure  and  functions  of  other 
neighbouring  parts  are  changed  and  impaired  by  the  con- 
tinuance of  a  tedious  aud  diseased  ulcerative  action.  This 
state  of  the  vein  being  once  induced  in  any  part  of  it,  and 
even  in  a  slight  degree,  two  consequences  follow  :  First, 
from  the  power  or  property  of  the  vein  being  impaired,  the 
blood  is  not  duly  propelled,  but  circulates  slowly,  and  can- 
not overcome  readily  the  weight  of  the  blood  above,  which 
presses  more  powerfully,  in  consequence  of  the  valves  being 
rendered  imperfect  by  the  distension  of  the  vessel.  The 
disease,  therefore,  gradually  increases  ;  for,  every  day,  the 
power  of  acting  properly  diminishes,  at  the  same  time  that 
the  mechanical  necessity  for  acting,  or  the  resistance  of  the 
column  of  blood  increases.  On  account  of  the  dilatation  of 
the  vessels,  and  the  morbid  or  abortive  effect  to  propel  what 
they  are  unable  to  do,  pain  is  produced,  in  the  course  of  the 
varix,  whenever  the  legs  are  kept  in  a  dependent  posture,  or 
exercise  is  used.  This  pain  is  confounded  with  the  uneasi- 
ness arisiug  from  the  ulcer  ;  and,  therefore,  these  ulcers  are 
said  to  be  painful,  and  to  be  attended  with  pain  in  the  course 
of  the  veins. 

The  second  consequence  is,  that,  as  the  veins  which  are 
more  immediately  connected  with  the  ulcerated  part,  are 
diseased,  and  do  not  perform  their  part  in  the  circulation 
properly,  the  functions  of  the  part  must  be  still  more  injured, 
and  the  varix,  which  originally  perhaps  was  produced  by  the 
ulcer,  comes  in  its  turn  to  act  on  the  sore,  and  prevent  its 
healing;  for  the  vein  not  acting  properly,  and  conveying  the 
blood  fully,  the  action  at  the  capillaries  must  be  injured,  and 
the  artery  and  vein  cannot  act  healthily.  If  this  be  the 
case,  the  power  of  forming  granulations  must  be  impeded. 


71 

and  these  never  can  be  deposited  in  the  necessary  degree 
of  perfection. 

Two  modes  of  cure  have  been  proposed,  the  one  pallia- 
tive, and  the  other  radical.  The  first  is  effected  by  means 
of  rollers,  or  bandages,  which  prevent  the  vein  from  being 
distended,  and,  therefore,  enable  it  the  better  to  carry  on  its 
circulatory  function.  In  this  way,  we  prevent,  to  a  certain 
degree,  the  hurtful  operation  of  the  vein  upon  the  ulcer,  and 
are  often  enabled  to  heal  it  up.  But,  as  we  do  not  thus  re- 
store the  vein  to  its  natural  powers,  unless  in  young  people, 
who  continue  the  support  or  pressure  for  years,  we  can  oh 
tain  no  permanent  cure  of  the  varix  ;  and  very  frequent  ly 
the  parts  again  ulcerate  ;  because,  whenever  the  pressure  or 
support  is  withdrawn,  and  the  patient  walks  about,  then  the 
function  of  the  part  becomes  affected,  the  organic  particles 
are  not  deposited  in  the  same  state  of  perfection,  and  the  ac- 
tion  which  is  induced  by  exercise,  causes  the  destruction 
of  these  granulations ;  or  even  the  very  circumstance  of 
their  being  formed  imperfectly  is  sufficient  to  produce  their 
destruction,  and  the  opening  of  the  part ;  for  all  parts  which 
have  been  formerly  ulcerated  are  most  ready  to  assume  this 
action  again,  and  the  organic  particles  of  that  part  are  less 
perfect,  and  less  able  to  bear  action. 

The  second  is  obtained,  by  obliterating  the  diseased  vein, 
or  interrupting  its  communication  with  the  trunk  above,  by 
which  wc  make  the  blood  take  a  different  course,  and  l>e 
transmitted  by  healthy  veins.  If  we  now  cure  the  sore,  we 
find,  that  the  same  effects  are  produced  as  if  we  used  per- 
manent pressure ;  and,  therefore,  the  functions  of  the  part 
are  more  properly  performed,  and  the  organic  particles  pos- 
sess greater  power  of  acting,  and  sustaining  action.  The 
older  surgeons  proposed  to  effect  the  radical  cure,  by  tying 
the  vein  at  the  two  extremities  of  the  diseased  part,  and 
cutting  out  the  intercepted  portion,  or  by  laying  it  open,  and 


digesting  it,  as  they  said.  This,  however,  was,  as  they  con- 
fess themselves,  very  seldom  submitted  to  in  ulcers  of  the 
legs ;  and  was  rather  inserted  to  complete  their  treatises, 
than  from  a  belief  that  the  operation  ought  to  be  insisted  on. 
Of  late,  it  has  been  proposed  by  Mr.  Home,  to  tie  only  the 
upper  extremity  of  the  diseased  portion,*  by  which  adhe- 
sion takes  place  at  that  spot,  and  the  circulation  is  there 
stopped.  The  pressure  of  the  blood  above  is  thus  taken 
off,  and  the  blood  from  below  must  circulate,  in  a  greater 
degree,  through  vessels  which  are  better  able  to  perform 
their  functions ;  and,  therefore,  the  actions  of  the  capillary 
vessels,  whether  nutrition,  absorption,  or  conversion  of  the 
blood  from  arterial  into  veinous,  must  be  more  naturally  per- 
formed. After  the  veins  are  tied,  they  gradually  become 
smaller  ;  for  the  pressure  being  permanently  removed,  the 
diseased  veins  can  more  fully  propel  their  blood  by  lateral 
branches,  at  the  same  time  that  they  receive  less  blood, 
more  going  by  other  vessels- 
It  is  a  curious  circumstance,  that  although  ulcers  may 
have  remained  in  an  indolent  state  for  many  years,  and  have 
become  almost  habitual,  that  yet,  the  cause  of  the  indolence 
being  removed,  they  recover  their  powers  rapidly,  and  with 
very  little  assistance.  Thus,  when  a  varix,  which  originally 
was  produced  by  the  ulcer,  reacts  on  the  sore,  and  prevents 
it  from  healing,  we  find,  that  if  this  cause  be  removed,  the 
Ulcer  frequently  heals  quickly,  owing  to  the  sudden  removal 
of  a  principal  cause  of  indolence,  although  a  similar  ulcer, 
without  varices,  would  not  be  cured  by  the  same  application 
in  the  same  time  ;  because  then  all  the  usual  causes  of  inda- 


*  This  operation  is  performed  by  making  an  incision  through  the  skin  which 
covers  the  vena  siphena  below  the  knee  ;  a  ligature  is  then  passed  under  the  ves- 
sel, by  me\ns  of  a  blunt  needle,  and  the  vessel  is  tied.  In  two  or  three  days  the 
ligature  may  be  removed,  its  circle  beiDg  previously  divided  with  a  pair  of  scis- 
tars. 


73 

lence  would  still  remain  to  be  removed,  or  their  effecfa 
counteracted ;  but,  in  this  case,  having  suddenly  removed 
one  great  cause,  the  action  rises  so  much,  that  it  can  over- 
come the  rest,  although,  without  this  alleviation,  the  healing 
process  would  not  be  commenced,  nor  continued.  It  may 
be  useful  to  attend  to  this  circumstance  in  every  case  of  in- 
dolent ulcers,  whether  attended  by  varices  or  not ;  because, 
if  we  can  remove  any  particular  cause,  we  do  much  toward 
producing  a  cure.  Thus,  callus  edges,  and  diseased,  or 
thickened  integuments,  &c.  although  originally  dependent  on 
the  ulcer,  yet  react  on  it,  and  prevent  it  from  healing.  If, 
t^ten,  by  pressure,  or  otherwise,  we  remove  these  causes,  we 
accelerate  the  cure. 

As  an  instance  of  the  good  effects  of  tying  varices,  I  shall 
transcribe  the  following  case  from  Mr.  Home's  Observations: 
"  A  man,  sixty  years  of  age,  had,  for  many  years,  gained  hia 
livelihood  by  going  on  messages,  having  been  rendered  unfit 
for  any  more  laborious  employment  by  a  large  ulcer  on  the 
left  leg,  just  above  the  inner  ankle.  The  complaint  was  of 
twelve  years  standing :  It  had  been  sometimes  much  better 
than  at  others,  but  had  never  been  well  during  the  whole  of 
that  period.  In  the  year  1792,  it  became  so  bad  as  to  con- 
fine him  entirely.  It  was  at  this  time  I  first  saw  him.  Upoii 
examining  the  limb,  the  veins  were  extremely  large,  and  vari- 
cose ;  and  the  trunk  of  the  vena  saphena,  at  the  knee,  ap- 
peared almost  the  size  of  the  little  finger.  The  size  of  this 
vein  led  me  to  the  idea  of  taking  it  up  at  that  part,  with  a 
view  of  relieving  the  lower  branches  from  the  pressure  of 
the  blood,  which  I  believed  to  be  the  cau%e  why  the  pari* 
remained  weak,  and  the  ulcer  could  not  be  healed.  I  ex- 
plained my  opinions  upon  this  subject  to  the  patient,  and 
told  him,  that,  if  he  thought  it  worth  while  to  try  it,  I  was 
very  ready  to  do  it  for  him.  The  man's  desire  to  get  well 
was  such,  as  to  induce  him  to  embrace  the  offer  of  any  mode 


71 

of  treatment  which  afforded  the  smallest  chance  of  it.  The 
vein  was  taken  up  in  the  way  that  I  have  mentioned :  He 
complained  of  very  little  pain,  no  improper  degree  of  in- 
flammation was  brought  on  by  this  operation,  the  ligature 
came  away  in  nine  days,  and  in  fourteen  the  wound  was 
healed. 

"  The  ulcer  upon  the  leg  was  dressed  with  dry  lint ;  it 
put  on  a  better  appearance  on  the  second  day  after  the  ope- 
ration ;  on  the  fourteenth  it  had  diminished  in  size  one  half ; 
and  in  twenty-eight  days  was  completely  healed.  He  was 
also  freed  from  a  pain  in  the  course  of  the  veins  of  that  le^, 
to  which  he  had  been  subject  for  many  years,  whenever  he- 
used  any  exercise. 

"  He  returned  to  his  business  of  carrying  messages,  and 
called  upon  me  a  year  after,  perfectly  well  ;  his  leg  having 
continued  sound." 

Issues  have  been  proposed  for  the  cure  of  this  genus  ol 
ulcers ;  but,  upon  the  principles  which  have  been  already 
mentioned,  it  must  be  evident,  that  they  can  be  of  little  or 
no  service ;  and,  I  am  sure,  that  I  never  saw  the  smallest  in- 
fluence exerted  by  them  over  an  ulcer.  They  are  useful, 
however,  after  the  ulcer  is  healed,  by  keeping  up  a  secreting 
action,  diminishing  the  risk  of  apoplexy,  &c.  ;  but  then  they 
ought  never  to  be  introduced  until  the  sore  be  nearly  healed, 
or  until  we  have  reason  to  suppose  that  the  sore  will  heal, 
and  that  they  will  be  required. 

The  treatment  of  this  genus  of  ulcers  may  be  comprised 
In  the  following  aphorisms  : 

First.  When  the  action  of  an  ulcer  becomes  too  low  and 
imperfect,  pressure  is  the  best  remedy  for  restoring  it  to  its 
proper  state,  and  for  accelerating  the  cure. 

Second.  Whenever  this  ceases  to  produce  any  farther  ef- 
fect, or  the  action  relapses,  and  begins  to  go  backward,  we 
must  lay  aside  the  pressure  for  a  time,  and  dress  the  sor^ 


•    75 

with  some  of  the  stimulating  applications  above  mentioned, 
particularly  the  nitro-mercurial  salts;  and  these,  in  their 
turn,  must  be  laid  aside,  when  they  cease  to  produce  a  good 
effect,  and  the  pressure  be  again  had  recourse  to. 

Third.  When  we  use  stimulating  dressings,  we  must  at- 
tend to  the  effects  which  they  produce  on  different  parts  of 
the  sore,  and  dress  these  differently,  according  to  their  con- 
dition. We  must  likewise  proportion  the  strength  of  appli- 
cation to  the  state  of  the  general  action.  Our  remedies  ought 
to  smart  most  when  the  action  is  most  torpid,  and  the  smart- 
ing ought  to  continue  longest ;  but,  when  the  action  has  be- 
gun to  be  more  perfect  and  vigorous,  the  same  application 
will  often  be  too  strong. 

Fourth.  We  must,  in  conjunction  with  this  general  plan, 
attend  to  particular  morbid  structures,  which  may  be  pro- 
duced by  the  particular  state  of  the  ulcer,  and  which  may  re- 
act on  it.  The  chronic  thickness  and  hardness  of  the  integu- 
ments, are  best  removed  by  pressure,  and  gentle  frictions  ; 
but  the  restoration  of  the  natural  structure  is  very  tedious. 
Callous  edges  are  likewise  best  removed  by  pressure.  When 
this  fails,  caustic  must  be  repeatedly  applied.  Varicose 
veins  may  be  palliated  by  firm  bandages,  but  are,  in  general 
after  they  have  continued  long,  only  to  be  cured  by  an  ope- 
ration. 

Fifth.  When  chronic  ulcers  can  be  healed,  it  is  useful  to 
form  an  issue,  in  order  to  keep  up  the  accustomed  secretory 
action;  but  these  issues  have  little  effect  in  advancing  the 
cure. 


vol.  it. 


76 
GENUS  in. 

Of  the  overacting  Ulcer. 

Tiiis  genus  comprehends  two  species :  First,  that  in  which 
I  he  granulating,  or  purulent  process  is  morbidly  increased,  or 
ihe  two  parts  of  the  ulcerative  action,  the  granulating  and 
the  purulent,  do  not.  correspond,  or  bear  the  same  propor- 
tion to  each  other  that  they  do  in  a  healthy  ulcer :  Se- 
cond, that  in  which  a  state  of  general  acute  overaction  takes 
place,  both  parts  of  the  ulcerative  action  being  equally  affect- 
ed, and  rendered  diseased. 

For  the  illustration  of  the  first  species,  I  may  remark,  that 
there  are  some  actions  performed  by  particular  parts  of  the 
body  which  are  apparently  simple ;  but  there  are  others  which 
are  complicated,  and  consist  evidently  of  different  parts, 
which,  in  the  aggregate,  form  a  peculiar  action,  but  which 
action  may  be  modified  according  to  the  degree  in  which 
these  different  parts  exist.  Thus,  there  are  various  parts 
which,  when  taken  together,  form  the  inflammatory  action, 
heat,  redness,  swelling,  &c. ;  but  these  may,  in  certain  cases, 
exist  in  different  proportions.  The  ulcerative  action  is  a 
complicated  one,  and  consists  of  the  secretory  and  organizing 
action,  or  the  purulent  and  granulating.  These,  in  a  healthy 
ulcer,  bear  a  certain  relation  to  each  other,  and  are  at  al! 
limes  so  connected,  that  when  one  part  is  injured,  the  other 
is  also  affected ;  but  the  one  part  maybe  affected  more  than 
the  other.  In  the  indolent  ulcer,  or  that  in  which  the  acj 
lion  is  too  low,  both  parts  are  most  commonly  (at  least  after 
some  time)  equally  affected,  and  a  state  of  universal  diminu 
tion,  and  consequent  imperfection,  takes  place ;  but,  in  the 
beginning  of  this  state,  that  is  to  say,  when  the  healthy  ulcer 
is  first  becoming  diseased,  and  when  the  unhealthy  condition 


77 

has  made  little  progress,  it  is  not  uncommon  to  observe  an 
inequality  in  the  action,  or  the  granulations  more  affected 
than  the  discharge.  In  this  genus  of  ulcers,  however,  the 
inequality  is  more  striking,  and  frequently  more  permanent. 

It  is  worthy  of  remark,  that  though  the  granulating  action 
may  be  increased  beyond  the  purulent  one,  that  yet  the  puru- 
lent one  never  exists  in  a  state  of  overaction  without  a  cor- 
respondent affection  of  the  granulating  action  ;  in  which  case, 
very  different  effects  and  symptoms  are  occasioned,  and  the 
second  species  of  overacting  ulcers  is  produced. 

The  first  species  has  generally  been  described  under  the 
name  of  the  fungous  ulcer,  or  ulcer  with  hypersacosis. 
The  ganulations  are  soft  and  indistinct.  They  are  imper 
fectly  formed,  and,  therefore,  do  not  possess  the  pointed 
appearance  which  they  exhibit  in  health ;  nor  have  they 
equal  powers  of  action,  nor  longevity.  They  are  formed 
quickly,  and  rise  to  a  greater  or  less  height  above  the  level 
of  the  surrounding  skin.  The  margins  are  generally  soft, 
tumid,  and  of  a  dull  red  colour.  The  discharge,  if  there  be 
no  carious  bone,  is  tolerably  thick,  and  of  a  white  colour, 
and  not  in  greater  quantity  than  would  be  yielded  by  a 
healthy  ulcer  of  the  same  size:  The  quantity  is  even  some- 
times less.  The  pain,  unless  when  a  bone  is  diseased,  is 
seldom  considerable.  This  species  admits  of  two  varie 
ties.  In  the  first,  the  granulating  process  is  increased,  in 
consequence  of  some  affection  of  the  action,  which  is  inde- 
pendent of  any  mechanical  cause.  In  this  case,  the  fun- 
gus is  generally  pretty  firm,  but  commonly  pale,  and  the  dis- 
charge tolerably  good.  In  the  second  variety,  the  granula- 
ting process  is  increased  in  consequence  of  some  mechanical 
irritation  underneath,  such  as  a  piece  of  carious  bone ;  and,  in 
this  case,  the  fungus  is  softer,  and  less  firm ;  it  is  of  a  redder 
and  more  lively  or  fiery  colour,  and  is  sometimes  covered, 
in  particular  parts,  .with  spots  of  lymph ;  it  bleeds  upon  the 


i lightest  touch.  The  sore  is  generally  painful,  and  the  dis- 
charge thin,  serous,  and  of  a  foetid  smell,  while  we  cau  fre- 
quently perceive  at  least  one  small  foramen  on  the  surface 
which  leads  down  to  the  bone,  and  through  which  it  may  be 
felt  to  be  rough.  Out  of  this  is  discharged  a  thin  matter  from 
the  bone  of  a  brownish  colour,  somewhat  like  soup,  and  more 
or  less  different  from  the  discharge  from  the  rest  of  the  sur- 
face. These  luxuriant  granulations,  however,  must  not  be 
confounded  with  those  which,  at  a  later  period,  come  from 
the  bone  itself,  after  it  has  begun  to  ulcerate.  These  are 
generally  of  a  more  florid  red  colour,  though  sometimes 
pale,  and  rise  up  either  through  chinks  of  the  bare  caries,  or 
from  such  portions  as  are  denuded  by  a  previous  exfoliation. 
They  have  in  general,  a  more  pointed  appearance  than  those 
which  arise  from  the  soft  parts,  so  that  in  many  cases,  the 
fungus  resembles  the  surface  of  a  strawberry,  being  rough. 
This  variety  may  be  induced  quickly,  the  bone  being  injured, 
at  the  same  time  that  the  soft  parts  arc  affected ;  but,  at 
other  times,  and  perhaps  more  frequently,  the  bone  becomes 
diseased,  in  consequence  of  the  continuance  of  a  simple  ulcer 
immediately  over  it ;  as,  for  instance,  on  the  tibia.  In  this 
case,  the  ulcer,  which  perhaps  was  formerly  indolent,  now 
changes  its  nature. 

The  second  species  exists  in  various  degrees,  and  its  symp- 
toms admit  of  modification  from  the  previous  state  of  the  ul- 
cer. Sometimes  an  ulcer,  although  previously  healthy,  has 
its  furface  excited  into  a  state  of  overaction,  by  exercise, 
or  other  causes.  In  this  case,  the  sore  becomes  painful,  and 
the  granulations  assume  first  a  kind  of  light  crimson  colour, 
and  then  a  brownish  hue,  from  a  species  of  mortification. 
They  do  not  indeed  become  gangrenous,  and  slough,  but  they 
approach  to  a  state  nearly  resembling  death,  and  are  absorb- 
ed. The  edges  are  slightly  erysipelatous,  and  the  discharge 
watery.     This  may  be  called  the  first  degree  or  stage  of  th$ 


79 

disease  ;  and  the  ulcer  frequently  recovers  soon  from  this, 
and  reassumes  its  healthy  condition.     But  if  it  be  neglected, 
or  the  injuring  causes  still  continue,  the  state  of  overaction 
is  increased,  and  becomes  more  perfect;*  that  is  to  say,  the 
actios  which  was  injured  in  its  different  parts,  and  rendered 
unconnected  by  the  incipient  or  new  condition,  becomes 
more  compleatly  and  connectedly  performed  in  its  differ- 
ent parts,   in  an  increased  degree.     The  overacting  state, 
which,  in  the  first  stage,  took  place,  perhaps  only  for  a  few 
hours,  or  at  least  if  it  continued,  did  not  rise  to  any  great 
degree,  or  receive  an  augmentation  in  this  stage,  continues 
with  violence,  and  generally  with  exacerbation.     The  gran 
ulations  are  absorbed  almost  as  soon  as  they  are  deposited  ; 
because,  owing  to  the  overaction  of  the  part,  they  are  veiy 
imperfectly  organized,  and  possess  very  little  life  and  power 
of  supporting  action.f      They  evidently  appear  to  be  in  a 
state  of  overaction  ;  for  they  are  fiery,  and  their  colour, 
whether  it  be  red  or  brownish,  is  bright  or  clear,  and  quite 
opposite  to  the  dull  hue  which  even  the  same  colour  may  have 
in  a  different  kind  of  sore.    These  bleed  upon  the  slightest 
touch ;  on  which  account,  the  discharge  is  generally  bloody. 
The  margins  are  red  and  ragged,  as  if  they  were  bitten  by 
a  mouse  ;  and  they  are  evidently  in  an  ulcerating  state.  The 
surrounding  skin  is  hot  and  erysipelatous,  the  discharge  is 
thin  and  serous,  and  the  pain  great,  generally  somewhat  of 
the  burning  kind.     This  sore,  from  the  destruction  of  the 
granulations,   and  the  propagation   of  a  morbid  degree  of 
action,  spreads  as  long  as  this  condition  continues  ;  but  the 
progress,  as  long  as  the  ulcer  belongs  to  this  genus,  or  as 
granulations  are  formed,  is  not  very  rapid. 


*  By  this  I  mean  more  perfect  in  its  state  of  overaction. 

t  In  highly  overacting  ulcers,  the  granulations  seem  to  possess  a  middle  state,  be- 
twixt proper  organic  particles  and  the  morbid  substance,  called  pus. 


80 

It  not  unfrequently  happens,  that,  after  a  sore  which  ha» 
been  indolent  has  begun  to  heal,  it,  from  fatigue,  or  some  less 
evident  cause,  has  a  state  of  overaclion  induced,  in  which 
rase,  different  appearances  are  exhibited,  according  to  the 
previous  state  of  the  sore.  If  it  has  begun  to  form  a  natural 
cicatrix,  this  gives  way,  the  surface  becomes  livid,  the  dis- 
charge thin,  and  the  pain  considerable.  A  thin  slough  of 
the  granulations  is  then  generally  formed,  and  comes  off  in 
portions  mixed  with  the  discharge.  If  this  state  be  not 
checked,  it  frequently  comes  to  exhibit  the  acute  symptoms 
of  the  overacting  ulcer  which  was  last  described.  More 
frequently,  however,  it  occurs  when  the  sore  is  still  indolent, 
and  not  in  the  healing  state,  and  when  the  edges  still  remain 
callous,  and  the  granulations  foul  and  unhealthy.  If,  at  this 
time,  a  disproportionate,  or  overaction  be  induced,  by  exer- 
cise or  otherwise,  we  find,  that  the  surface  becomes  dark  and 
gloughy,  the  granulations  flat  and  indistinct,  the  discharge  is 
increased,  and  the  margins  become  tumid,  and  of  a  modena 
colour,  whilst  the  surrounding  integuments  are  of  a  dull  red 
mottled  colour,  or  erythematous  ;  and  the  foot,  if  it  take 
place  in  the  leg,  is  frequently  cold,  and  the  pain  darts  down 
to  the  toe. 

This  state  is  not  unfrequently  produced  in  old  ulcers,  by 
a  disease  of  the  parts  below,*  which  has  been  induced  by 


*  This  affection  of  the  ulcer,  produced  by  a  disease  of  the  parts  below,  is  in- 
duced with  a  frequency  nearly  proportioned  to  (he  aptitude  of  the  part  below  for 
becoming  diseased,  by  the  continuance  of  an  ulcer  over  them.  Tendons  and 
bones  are  particularly  apt  to  be  injured  in  this  way;  and,  therefore,  ulcers  seat- 
«d  over  tendinous  part",  or  bones  thinly  covered,  are  more  apt  to  affect  these, 
and  to  be  reacted  on  themselves,  than  when  seated  over  fleshy  parts.  On  the 
same  account,  ulcers  on  the  foot,  or  ankle  joint,  are  worse  to  heal  than  those  a. 
little  farther  up  the  leg  ;  and  the  difference  is  greater  than  ean  be  explained  whol- 
ly, by  the  circumstance  of  distance  from  the  heart,  and  possessing  less  power  of 
performing  action  properly.  Recent  ulcers  likewise  heal  easily  on  the  feet,  by 
proper  treatment.  It  is  old  ulcers  alone  which  are  difficult  to  manage,  and  th,t 
'ause  is  obviou?. 


81 

the  long  continuance  of  the  ulcer,  which  renders  the  bone 
carious,  if  it  lie  immediately  under  it  (in  which  case,  the  first 
species  of  overacting  ulcers  is  produced ;)  but,  at  other 
times,  by  the  sympathy  of  association,  a  diseased  formative 
action  (owing  to  the  diseased  formative  action  in  the  ulcer, 
or  the  imperfect  granulations  which  are  formed)  is  induced 
in  the  neighbouring  parts,  the  muscles  become  pale,  and  have 
less  of  their  fibrous  texture,  or  the  bone  becomes  rough,  or 
pointed,  like  shagreen,  and  also  becomes  thickened,  but 
without  any  appearance  of  caries.  This  diseased  condition 
of  the  parts  reacts  on  the  ulcer,  and  induces  overaction. 

This  state  of  overacting  may  also  be  induced  in  old  ul- 
cers, without  any  malformation  of  the  parts  below,  but 
merely  in  consequence  of  continuance  ;  for,  after  an  ulcer 
has  remained  long  indolent,  it  comes  to  act  so  imperfectly, 
that  it  naturally  goes  beyond  its  power.  This  may  be  said 
to  be  a  spontaneous  change,  or  conversion  of  one  genus  into 
another. 

We  have  then  two  varieties  of  this  species:  First,  the 
state  of  overaction  induced  in  an  ulcer  which  was  previously 
healthy  ;  and  this  admits  of  two  stages,  the  incipient  and 
confirmed  :  The  first  sometimes  consists  only  of  one 
short  paroxysm ;  the  second  continues  for  a  longer  time, 
and  generally  depends  upon  the  neglect  of  the  first  attack. 
Second,  the  state  of  overaction  induced  in  an  ulcer  which 
has  previously  been  indolent ;  and  this  admits  of  two  sub- 
divisions, which  arise  from  the  condition  of  the  ulcer  at  the 
time  of  its  overacting,  namely,  whether  it  have  been  heal- 
ing and  cicatrizing,  or  the  edges  have  been  callus,  and  the 
action  imperfect  and  morbid. 

The  observations  on  the  cure  of  this  genus  of  ulcers  must 
naturally  be  arranged  under  the  different  species  and  varie* 
ties  of  these  ulcers. 


si 

in  the  first  variety  of  the  first  species,  our  object  is  to  re- 
move the  supernumerary,  or  fungous  granulations,  and  to  re 
place  them  with  others,  which  are  formed  more  slowly,  and 
in  greater  perfection. 

Pressure,  applied  in  the  manner  already  explained,  is  one 
of  the  most  useful  remedies  in  this  variety,  and  ought  always 
to  be  tried  first.  The  luxuriant  granulations  are  quickly  ab- 
sorbed, and  the  succeeding  ones  are  rendered  more  compact 
and  healthy,  and  the  cicatrix  begins  to  be  formed.  If,  how- 
ever, we  apply  pressure  in  this,  or  indeed  in  any  sore,  to 
such  a  degree  as  to  produce  its  specific  effect,  we  must 
counteract  its  irritation  by  cold.  If  we  do  not,  this  sore  is 
frequently  converted  into  the  second  variety  of  the  second 
species  of  this  genus. 

Caustic,  and  escharotics,  have  been  sometimes  applied  t» 
these  sores  ;  but  they  only  remove  a  layer  of  granulations, 
without  affecting  the  formation  of  the  succeeding  ones  so 
much  as  some  other  remedies. 

Stimulating  applications  are  more  useful  ;  for,  as  they  act 
more  slowly,  they  produce  a  greater  influence  on  the  action. 

The  cuprum  vitriolatum,  mixed  with  simple  ointment,  in 
the  proportion  of  a  drachm  to  the  ounce,  is  frequently  ser- 
viceable ;  but  the  ung.  hyd.  nit.  is  still  more  useful.  One 
drachm  of  this  may  be  mixed  with  an  ounce  of  hog's  lard 
and  a  scruple  of  camphor.  Red  precipitate,  mixed  with 
resinous  ointment,  is  also  often  of  service. 

The  application  of  powdered  rheubarb  is  recommended 
L>y  Mr.  Home,  and  is  frequently  of  service. 

Lotions  of  port  wine,  solutions  of  white  vitriol,  or  roso 
water,  containing  as  many  drops  of  l'eau  mercurielle*  a^ 
will  make  it  moderately  pungent,  maybe  usefully  applied  be 
fore  the  dressing. 

•  L'eau  mercuriellc  is  a  solution  of  mem?r7  in  nitrous  acid. 


Poultices  seem  to  increase  the  diseased  state  ;  and  mild 
dressings  do  not  counteract  it,  but  allow  it  to  go  on. 

The  second  variety  is  only  to  be  cured  by  removing  the 
caries  bone  ;  but  the  same  remedies  which  are  used  in  the 
first  variety  may  be  employed  here,  as  palliatives,  or  the 
means  of  preventing  the  ulcer  from  becoming  worse.  By  a 
continuance  of  these  applications,  in  cases  of  slight  caries, 
a  cure  may,  after  some  time,  be  obtained ;  for  the  thin  layer  of 
diseased  bone,  either  comes  away  in  fragments  through  an 
opening  in  the  ulcer,*  or  it  is  sometimes  absorbed.  This 
last  event,  the  absorption  of  the  bone,  is  particularly  indu- 
ced by  pressure,  applied  by  means  of  the  adhesive  plaster  ; 
and,  therefore,  where  the  disease  is  not  extensive,  it  is  al- 
ways proper  to  have  recourse  to  this  ;  but  if,  upon  trial,  we 
find  it  to  fail,  or  to  convert  the  sore  into  the  second  species 
of  this  genus,  which  it  sometimes  does,  we  must  omit  it. 

As  it  is  only  in  slight  cases  of  caries  that  absorption  of 
the  bone  is  to  be  expected,  we  may  consider  it  as  necessary, 
in  general,  as  a  preparatory  step  toward  healing,  that  the 
diseased  portion  of  the  bone  be  separated,  and  come  away 
externally.  It  is  therefore  of  advantage  to  endeavour  to  ac- 
celerate this  ;  because,  whatever  does  so,  hastens  the  cure. 
Our  attempts,  with  this  view,  are  made  at  two  different 
stages,  and  with  different  intentions.  First,  when  the  bone 
has  separated,  or  exfoliated  from  the  part  below,  by  making 
an  incision  through  the  ulcerated  surface,  we  remove  the 
dead  part,  and  allow  the  sore  to  heal.  This  stage  may  be 
discovered,    by   pushing  a  probe   through   the  opening,   if 


*  In  the  description  of  this  variety,  it  was  mentioned,  that  there  frequently 
was  a  small  opening  in  the  surface,  which  communicated  with  the  bone  ;  but,  even 
where  this  is  not  the  case,  the  layer  of  dead  bone,  when  it  exfoliates,  comes 
through  the  granulations  ;  for  the  granulations  of  the  sound  bone  below  raise  it 
up,  in  consequence  of  which,  pressure  1*6  made  from  within  outward  upon  the  ul- 
cer, by  which  absorption  is  produced  at  that  part,  in  a  greater  degree  than  depo 
sition  ;  and,  therefore.,  a  vacuity  is  produced. 
VOt.    II.  L 


84 

there  be  one,  or  through  the  granulations,  down  to  the  layer 
of  bone,  which  we  find  to  be  elastic  when  we  press  on  it. 
But,  even  although  the  incision  be  made  before  this  stage 
has  taken  place,  no  harm  is  done,  because  it  is  of  use  in  the 
first  stage.  Second,  when  the  carious  bone  has  not  yet  ex- 
foliated, but  remains  in  contact  with  the  rest  of  the  bone, 
ulceration  of  the  sound  part  not  having  yet  taken  place,  it 
will  be  useful  to  make  an  incision  down  to  the  bone,  and,  as 
soon  as  the  bleeding  stops,  or  lessens,  to  apply  caustic  freely, 
in  the  whole  course  of  the  incision,  so  as  to  act  upon  the 
caries,  or  rough  portion  ;  or  we  may  use  the  trephine,  or 
other  remedies,  which  have  been  formerly  mentioned.  It 
sometimes  happens,  that  the  soft  parts  are,  at  particular  por- 
tions, and  often  to  a  considerable  extent,  removed  by  absorp- 
tion, and  the  bone,  at  these  parts,  is  left  bare.  In  this  case, 
no  incision  is  necessary,  except  occasionally  through  some 
bauds  of  granulations  which  extend  across  the  bare  bone  ; 
and,  therefore,  we  can  at  once  apply  our  remedies  to  the 
bone,  or  make  perforation  with  the  trephine. 

The  second  species  requires  to  be  treated  differently,  ac- 
cording to  it3  varieties. 

As  the  incipient  stage  of  the  first  variety  frequently  con- 
sists of  only  one  short  paroxysm,  it  would  often  be  unnecessa- 
ry to  have  recourse  to  any  peculiar  treatment ;  but,  as  it  is 
impossible,  a  prior?,  to  say  whether  the  state  of  evacuation  is 
to  continue,  it  is  requisite,  in  every  instance,  to  vary  our 
treatment,  and  apply  the  proper  remedies  for  the  disease. 

Poultices  are  frequently  useful  in  this  kind  of  ulcer,  when 
the  surface  is  dark  coloured,  and  the  integuments  are  not 
yet  affected.  They  have  sometimes  an  effect  of  checking 
the  morbid  state,  if  this  be  not  already  done ;  but  they 
more  generally  promote  the  absorption  of  the  morbid  granu- 
lations, after  which  the  surface  becomes  healthy.  If,  how- 
ever, the  action  be  still  greater,  and  more  permanent,  theix 


85 

the  ulcer  is  tending  toward  the  confirmed,  or  perfect  state 
of  overaction,  and  poultices  are  not  of  equal  service ;  they 
are  even  sometimes  hurtful. 

Gentle  pressure,  accompanied  with  the  use  of  cold  water, 
is  of  service  in  the  same  cases  in  which  poultices  are  em- 
ployed ;  that  is  to  say,  when  the  action  has  not  become  per- 
fect, but  has  rather  begun  to  subside,  and  the  granulations 
remain  dark  coloured,  and  in  a  dying  state.  They  are  ab- 
sorbed, and  replaced  with  more  perfect  and  healthy  granu- 
lations. 

When,  however,  the  action  still  continues  in  the  same 
state  of  overacting,  or  seems  to  be  increasing,  these  remedies 
are  rather  hurtful ;  and  we  will  derive  more  benefit  from 
using  applications  of  a  gentle  stimulating  nature,  which  re- 
store the  action  to  a  more  perfect  and  natural  state,  in  the 
same  way  as  they  cure  the  inflammatio  debilis.  For  this 
purpose,  one  *)f  the  best  applications  is  the  following  : 

R.  Opii  drachmas  duas, 
Camphora?  scrupulum. 

Vini  Albi  uncias  quatuor.     Macera  per  triduum, 
dein  cola. 

This  may  be  applied  by  means  of  a  bit  of  lint  to  the  sore. 
It  generally  produces  considerable  smarting  for  a  few  minutes, 
after  which  the  pain  abates.  The  application  is  to  be  re- 
peated every  hour,  or  every  two  hours,  until  the  sore  begins 
to  look  healthy,  and  the  pain  abates.  The  adhesive  plaster 
ought  then  to  be  substituted  in  its  place. 

Laudanum  may  also  be  employed  with  the  same  intention^ 
but  it  is  inferior  to  the  other. 

Lemon  juice  is  also  sometimes  useful,  and  may  be  employ- 
ed where  the  opiated  wine  fails,  or  is  not  at  hand. 


8fr 

When  the  state  of  overaction  becomes  confirmed,  and 
progressive,  the  sore  spreads,  becomes  very  painful,  and  as- 
sumes the  appearances  which  have  been  already  described. 
In  this  case,  the  application  of  carrot,  or  turnip  poultices,  is 
frequently  useful.  These  vegetables  are  sometimes  made 
into  a  poultice  by  boiling  them,  and,  at  other  times,  by  rasp- 
ing them  down  raw. 

Camomile  flowers,  boiled  in  milk,  and  then  expressed, 
yield  a  decoction,  which,  when  made  into  a  poultice  with 
crumb  of  bread,  frequently  abates  the  pain.  Sometimes  the 
application  of  cloths,  dipped  in  fine  oil,  give  relief. 

These  sores  are  also  frequently  reduced  to  a  more  healty 
state,  by  applying  cloths  dipped  in  the  following  mixture ; 

R.  Amnion.  Hepatizatae*  guttas  decern. 
Aq.  Font,  uncias  octo. 

This  produces  a  moderate  degree  of  smarting  for  a  little 
time,  during  which  the  former  painful  sensation  arising  from 
the  sore  lessens,  and  does  not  return  for  some  time.  When 
the  peculiar  pain  of  the  ulcer  again  manifests  itself,  the  so- 
lution is  again  to  be  applied. 

An  ointment,  consisting  of  two  drachms  of  powdered  opU 
urn,  and  one  ounce  of  simple  cerate,  is  also  a  very  useful  ap- 
plication. 

Sprinkling  the  sore  with  red  precipitate,  or  touching  the 
surface  with  caustic,  frequently  stops  the  disease. 

The  kind  of  erythematous  affection,  which  frequently  af- 
fects the  surrounding  skin,  is  best  removed  by  stimulating 
applications,  which  abate  the  pain  or  hot  sensation,  and  make 
it  less  apt  to  ulcerate.     The  following  is  a  very  useful  ap- 


*  The  ammonia  hepatizata  is  prepared  by  passing  a  stream  of  hepatic  gas 
through  the  aqua  ammoniae. 


87 

plication  for  this  purpose.     The  affected  part  is  to  he  light 
ly  dusted  with  it  occasionally  : 

R.  Hyd.  Precip.  Rub.  line.  i. 
Pulv.  Opii  semiunc. 

Cretae  Ppt.  unc.  ii.     Tere  simul  ut  fiat  pulvis  sub- 
tiliss. 

When,  by  any  of  these  applications,  the  state  of  overac- 
tion  is  overcome,  pressure  is  the  best  remedy  for  pic- 
serving  our  ground,  and  producing  a  cure  ;  for,  remedies 
which  may  be  useful  in  the  diseased  state,  will  be  hurtful 
when  this  state  is  removed. 

In  this  sore,  anodynes  are  to  be  freely  employed  internal- 
ly ;  for,  given  sparingly,  they  do  no  good.* 

All  the  applications  ought  to  be  made  gently,  and  lightly  ; 
because  any  mechanical  irritation  increases  the  disease. 

The  second  variety  of  this  species  is  a  very  troublesome 
ulcer,  and  admits,  as  has  been  already  observed,  of  two  di- 
visions :  First,  it  not  unfrequently  happens,  that,  after  an  in- 
dolent ulcer  has  been  in  a  healing  state  for  some  time,  a  state 
of  overaction  is  induced,  by  fatigue,  or  other  causes,  parti- 
cularly by  the  natural  inability  of  the  newly  formed,  and 
not  completely  perfect  granulations,  to  sustain  the  action 
which  is  necessarily  induced  in  them  by  their  connexion 
with  other  parts  (upon  the  principle  of  the  communication 
of  action.)  In  this  case,  the  sore  becomes  foul,  dark  colour- 
ed, and  painful,  whilst  the  cicatrix  ulcerates,  and  the  new 
granulations  die,  so  that,  in  a  short  time,  the  ulcer  regains 


*  No  external  application  whatever  will  produce  the  same  good  effect,  if  used 
by  itself,  as  when  such  a  general  action  is  induced  as  shall  co-operate  with  the 
local  remedies.  In  slight  cases,  thirty  drops  of  laudanum  may  be  given  twice  a- 
day ;  but,  when  the  overartinn  is  more  violent,  ibe  dose  must  be  more  frpqurn'tr 
•repeated. 


38 

*ts  original  size,  and  even  spreads  slowly  to  a  greater  extent. 
Second,  an  old  ulcer  may,  without  having  been  previously 
in  a  healing  state,  become  converted  into  the  overaciing  ul- 
cer ;  because  the  surface  has  its  power  so  weakened,  that 
common  agents,  which  naturally  excite  action  in  the  pari, 
excite  a  disproportioned  and  morbid  action  in  the  ulcer  ; 
but  this  action  is  of  the  low  kind,  and  bears  somewhat  the 
same  relation  to  the  first  species,  (or  overacting  ulcerative 
action,  in  ulcers  previously  healthy,)  that  the  inflammatio 
debilis  does  to  the  inflammatio  valida.  In  this  case,  the 
surface  is  bloody,  and  the  half-formed  granulations  are  of  a 
livid  colour  ;  the  callus  edges  are  of  a  dusky  red,  or  mode- 
na  colour ;  the  integuments  are  generally  mottled  ;  the  in- 
ferior part  of  the  limb  is  cold  and  painful. 

In  the  cure  of  the  first  division,  we  must  enjoin  rest,  as  in 
the  second  variety  of  the  first  species,  and  apply  cloths, 
dipped  in  a  mixture  of  two  parts  of  laudanum  and  one  of 
camphorated  spirit  of  wine,  which  produces  at  first  consi- 
derable smarting ;  but  the  sensation  is  different  from  the 
former  pain;  and,  although  uneasy,  is  yet  more  tolerable 
than  the  peculiar  pain  of  the  ulcer.  This  application  ought 
to  be  renewed  two  or  three  times  in  the  course  of  the  day, 
until  the  surface  becomes  of  a  better  appearance,  and  the 
pain  abates. 

The  application  of  the  powder  of  bark  to  these  sores  is 
sometimes,  but  very  seldom,  of  service.* 

A  poultice,  formed  of  decoction  of  camomile  flowers,  opi- 
nm,  and  charcoal,f  is,  frequently  of  use,  and  should  be   cm- 


*  This  was  probably  recommended  on  account  of  the  sphacelated  appearance 
■which  these  sores  somefiines  have. 

t  Let  two  ounces  of  camomile  flowers  be  boiled  in  three  pounds  of  water  down 
to  two.  \\  hen  this  is  cold,  it  ought  to  be  strained,  and  half  a  drachm  of  opium 
■diffused  in  a  pound  of  the  decoction.  Of  this,  a  sufficient  quantity  is  to  be  added 
i*o  powdered  charcoal,  in  order  to  form  a  poultice. 


89 

ployed  when  the  laudanum  and  camphorated  spirit  fail.  This 
should  be  applied  cold. 

In  the  second  division,  the  fermenting  poultice*  is  often 
of  service ;  but  it  must,  like  all  other  applications,  be  con- 
tinued no  longer  than  the  state  which  it  was  intended  to  re- 
move remains.  Jf  we  continue  it  too  long,  we  do  hurt ;  for, 
if  it  be  kept  on  when  it  produces  continued  pain,  it  induces 
a  state  of  overaction,  similar  to  that  which  it  was  intended 
to  destroy.  Whenever  the  surface  becomes  redder,  and  the 
pain  less,  it  may  be  useful  to  employ  some  other  application, 
such  as  laudanum,  &c. 

The  same  observations  apply  to  the  use  of  the  gastric 
juice.  Cloths  dipped  in  this  sometimes  make  the  overacting 
surface  slough  oft*,  and  leave  the  parts  below  more  healthy. 
The  same  may  be  said  of  the  expressed  juice  of  sorrel. 

Lime  water  sometimes  operates  in  the  same  way. 

Red  precipitate,  mixed  with  its  weight  of  powdered  opium, 
and  half  its  weight  of  camphor,  may  be  usefully  sprinkled 
over  the  surface. 

A  pound  of  the  recent  leaves  of  hemlock,  boiled  for  half 
an  hour  in  two  pounds  of  milk,  and  then  expressed,  forms  an 
application  which  sometimes  abates  the  pain,  and  renders  the 
action  more  healthy.  The  juice  is  to  be  made  into  a  poul- 
tice with  crumb  of  bread. 

Decoction  of  the  walnut  tree  leaves,  applied  by  means  of 
pledgets  of  linen,  or  made  into  a  poultice  with  bran,  is  oc- 
casionally of  service. 

When,  by  any  of  these  applications,  the  morbid  state  of 
the  ulcer  is  removed,  it  is  to  be  dressed  according  to  the 
genus  into  which  it  is  then  converted. 


*  The  fermenting  poultice  19  made  by  adding  a  spoonful  of  yest  to  an  oatmeal 
poultice,  and  placing  it  before  the  fire  until  it  begins  to  emit  air,  or  rise  up  Hi  a 
babbling  way.    It  is  then  fit  for  applying  to  the  sore. 


90 

After  these  remarks,  the  treatment  of  this  geims  of  ulcers 
may  be  comprised  in  the  following  observations  : 

First.  In  the  first  variety  of  the  first  species,  or  the  sim- 
ple fungous  ulcer,  the  cure  is  to  be  attempted  by  pressure, 
and  gentle  stimulants,  which  render  the  action  more  natural, 
and  the  granulations,  in  consequence,  more  perfect  and  com- 
pact. 

Second.  In  the  second  variety  of  this  species,  we  are  to 
employ  the  same  remedies,  as  palliatives,  or  as  means  which 
may  promote  the  exfoliation  of  the  bone.  But,  if  the  dis- 
ease in  the  bone  be  more  extensive  and  tedious,  we  must  cut 
down  through  the  ulcer,  and  apply  caustic,  or  mechanical 
cures,  such  as  perforation,  to  the  caries. 

Third.  In  the  incipient  stage  of  the  first  variety  of  the 
second  species,  we  must  avoid  motion,  and  all  other  such 
causes  as  tend  simply  to  increase  action.  When  the  disease 
has  consisted  of  one  short  paroxysm,  which  has  terminated, 
we  must  promote  the  absorption  of  the  diseased  granulations, 
and  the  process  of  replacing  them  with  others  which  are 
more  perfect,  which  is  effected  by  such  remedies  as  render 
the  action  which  forms  them  more  natural.  This  is  best 
done  by  gentle  pressure,  and  sometimes  by  poultices.  If, 
however,  the  paroxysm  continue  longer,  but  in  a  moderate 
degree,  we  must  use  such  applications  as  tend  more  directly 
1o  change  the  action,  and  diminish  the  morbid  condition  ; 
such  as  camphorated  and  opiated  preparations,  and  sometimes 
the  vegetable  acids. 

Fourth.  When  this  state  becomes  confirmed  and  progres- 
sive, the  action  being  violent,  we  must  use  remedies  nearly 
similar  to  those  which  are  employed  in  the  last  case,  and 
which  are  useful  in  the  cure  of  the  inflammatio  debilis,  at 
the  same  time  that  we  enjoin  rest,  and  keep  the  part  as  easy 
as  possible.  In  some  instances,  the  action  cannot  be  over- 
come directly  by  any  application,  but  is  rather  increased  by 


91 

them.  In  this  case,  wo  must  lay  these  aside,  and  use  mild 
and  light  applications  ;  such  as  fine  oil,  fresh  cream,  &c. ;  at 
the  same  time  that  we  avoid  the  general  causes  tending  to 
increase  action ;  such  as  motion,  heat,  spirits,  Fee. 

Fifth.  When  this  state  occurs  in  chronic  ulcers,  we  must 
use  such  remedies  as  tend  to  remove  the  dead  or  dying  gra- 
nulations which  frequently  cover  the  surface,  and  such  as  at 
the  same  time  produce  a  more  natural  action,  and  restore  to 
the  succeeding  granulations  greater  powers  and  perfection, 
and  a  more  healthy  mode  of  acting.  Stimulating  applications 
frequently  have  this  effect ;  such  as  the  fermenting  poultice, 
precipitate  ointment,  &c.  ;  at  other  times,  narcotic  applica- 
tions ;  such  as  cicuta,  &c.  are  useful. 

Sixth.  In  these  ulcers,  the  redness  and  pain  of  the  skin 
which  surrounds  the  ulcer,  is  to  be  treated  as  the  inflamma- 
tio  assuefacta,  by  being  dusted  with  the  powder  which  has 
been  already  mentioned,  or  by  similar  remedies. 

Seventh.  In  all  of  these  ulcers,  where  the  action  is  violent, 
much  benefit  will  be  derived  from  inducing  the  general  nar- 
cotic action  to  a  considerable  extent.  Anodynes  are  there- 
fore to  be  freely  administered,  at  the  same  time  that  we  em- 
ploy the  proper  local  remedies. 

Eighth.  Whenever  the  ulcer  becomes  more  healthy,  and 
the  action  less  morbid,  the  strength  of  the  application  is  to 
be  diminished;  and,  when  the  slate  of  overaction  is  destroy- 
ed, it  must  be  treated  as  the  indolent  ulcer,  because  the 
granulations  are  still  feeble.  Pressure  is  most  useful  in  this 
case. 


VOL.  II.  M 


92 

GENUS  IV. 

Of  the  Inflammatory  Ulcer. 

It  sometimes  happens,  that  the  ulcerative  action  becomes 
converted  into  the  inflammatory ;  the  discharge  diminishes, 
and  sometimes  ceases  ;  the  surface  is  red ;  and  the  edges 
and  surrounding  skin  are  elevated  and  inflamed.  This, 
which  has  been  called  the  phlogosis  ulceris,*  strictly  speak- 
ing, does  not  belong  to  the  division  of  ulcers,  because  the 
ulcerative  action  is  destroyed  ;  but,  as  it  is  preceded,  and 
very  quickly  followed  by  this  action,  and  as  the  solution  of 
continuity,  and  other  external  appearances  continue,  this  af- 
fection may  be  allowed  to  rank  as  a  genus  among  ulcers,  in 
conformity  to  common  language. 

When  the  pain  and  inflammation  are  considerable,  leeches 
are  frequently  applied  with  utility  in  the  vicinity  of  the 
sore ;  but  it  is  more  generally  useful  to  apply  warm  poultices, 
which  restore  the  secretory  state,  and  the  ulcerative  ac- 
tion. 


GENUS  V. 

Of  the  Suppurating  Ulcer. 

This  genus,  like  the  last,  accurately  speaking,  does  not 
belong  to  the  class  of  ulcers ;  but,  as  it  is  so  intimately  con- 

*  Siccitas  rubid&et  j<hiogosis  ulceiis  facile  cognoscunter ;  dolore,  pruritu,  calore 
stipaatur;  ea  impediunt  carnis  excrescentiam,  adeogue  indicant  reuiedia  emolli- 
cntia,"  &c.    Sauvage  Nosol.  Meth.  torn.  ii.  p.  613. 


93 

nected  with  it,  both  in  its  causes,  and  treatment,  and  appear- 
ances, it  is  of  some  practical  utility  to  admit  the  arrange- 
ment. 

When  an  abscess  is  opened  before  the  ulcerative  action  is 
induced,  we  have  an  open  suppura?  ing  sore  ;  but  this  is  not 
the  sore  which  is  meant  to  be  described  here. 

The  suppurating  ulcer  is,  when  simple,  and  independent 
of  any  specific  action,  most  frequently  only  a  high  degree  of 
the  overacting  ulcer  ;  but,  as  its  symptoms  are  somewhat 
different,  and  as  it  nearly  resembles  some  specific  sores,  dif- 
fering from  these  only  in  the  absence  of  the  peculiar  action, 
resulting  from  the  application  of  a  poison,  it  may  be  proper 
to  consider  this  as  a  separate  genus. 

When  the  ulcerative  action  is  very  imperfectly  carried 
on,  which  often  arises  from  overaction,  we  find,  that  the  or- 
ganic particles  are  thrown  out,  not  in  the  form  of  granula- 
tions, but  in  a  more  inorganic  state,  and  lie  upon  the  surface, 
mixed  with  the  discharge  from  the  other  set  of  vessels. 
This  has  the  appearance  of  very  thick  tough  pus,  and  the 
sore  which  yields  it  may  properly  be  considered  to  be  in  a 
suppurating  state.  This  ulcer  is  distinguished  by  the  pain 
which  attends  it,  by  a  redness  which  surrounds  the  margin, 
and  a  hardened  base,  whilst  the  cavity  of  the  ulcer  is  filled 
up  with  a  thick  straw-coloured  substance,  somewhat  like 
lymph,  which  adheres  firmly  to  the  surface.  This  is  impro- 
perly called  a  slough. 

This  appearance  and  condition  may  be  excited  in  a  simple 
ulcer,  without  any  apparent  application  of  contagion  ;  but 
it  is  still  more  frequently  the  consequence  of  some  morbid 
matter  acting  on  the  part,  and  producing  specific  ulceration, 
which  will  be  afterwards  considered.  I  may  only  here  ob- 
serve, that  it  has,  in  some  of  these  cases,  been  considered  as 
a  species  of  gangrene,  as,  for  instance,  in  the  cynanche  ma- 
ligna ;  but,  whatever  may  take  place  in  the  advanced  stages 


94 

of  this  disease,  there  is  at  first  no  grangrene,  but  a  suppura- 
ting ulcer,  wh;ch  throws  out  imperfect  granulations,  or 
rather  a  morbid  purulent  discharge,  (for  the  one  runs  natu- 
rally into  the  other,)  which  forms  what  is  called  a  slough. 

The  treatment  of  this  ulcer  consists  first  in  procuring  a 
separation  of  the  tenacious  covering,  by  such  remedies  as 
shall  at  the  same  time  that  they  do  this,  make  the  action 
more  healthy. 

A  pretty  strong  solution  of  the  argentum  nitratiun,  or 
l'eau  mercurielle,  diluted  with  equal  parts  of  distilled  water, 
applied  by  means  of  a  brush,  frequently  produce  the  desired 
effect. 

The  acetous  infusion  of  Cayenne  pepper  applied  in  the 
same  way,  is  likewise  useful. 

Poultices  made  of  decoction  of  camomile  flowers,  and  equal 
parts  of  charcoal  and  barley  meal,  are  sometimes  of  service 
in  removing  the  matter,  and  rendering  the  action  more  truly 
ulcerative. 

Opiates  ought  to  be  freely  administered. 

When  this  state  of  the  sore  is  removed,  the  ulcer  must  be 
treated  according  to  the  condition  of  the  ulcerative  action. 
Most  frequently  it  belongs  first  to  the  overacting  genus,  and 
must  be  treated  accordingly,  and  then  to  the  genus  of  indo- 
lent ulcers,  in  which  case,  pressure  is  to  be  employed  as  a 
termination  to  the  cure. 

When  an  overacting  ulcer  has,  without  the  assistance  of 
local  applications,  ceased  to  overact,  it  not  unfrequently  sup- 
purates ;  that  is  to  say,  no  granulations  are  formed,  but  the 
two  sets  of  vessels  throw  out  an  inorganic  matter,  and  the 
surface  of  the  sore  has  a  lymphatic  appearance. 

The  best  dressing  for  this  state  is  dry  lint  with  a  pledget 
spread  with  cerate  laid  over  it. 


95 


Of  the  Effects  of  the  Ulcerative  action  on  the 
Constitution. 

The  condition  and  qualities  of  an  ulcer,  do  not,  in  every 
instance,  depend  upon  causes  which  are  entirely  local,  but 
frequently  are  connected  with  some  general  state,  or  mode  of 
action,  of  the  system.  General  weakness  must,  for  example, 
influence  the  performance  of  any  action  in  a  particular  part ; 
and,  therefore,  an  ulcer  in  those  who  are  infirm,  and  exhaust- 
ed, cannot  readily  perform  the  necessary  healthy  action,  or 
proceed  quickly  toward  a  cure  ;  nor  is  it  easy,  in  these  circum- 
stances, by  any  local  applications,  to  communicate  the  neces- 
sary action,  and  the  correspondent  power,  which  shall  ena- 
ble the  part  to  heal.  In  the  same  way,  there  are  some  people 
so  irritable,  that  an  ulcer  shall  very  readily  assume  the  over- 
acting state  which  can  only  be  removed  by  such  remedies  as 
act  on  the  general  system.  Besides  those  which  may  be  con- 
sidered as  simple  conditions,  there  are  many  other  actions, 
which  are  peculiar  and  unnatural,  which  influence  the  ulcer, 
or  in  which  ulcers  often  appear  as  symptoms.  These  ulcers 
are  specific,  and  must  be  afterwards  considered. 

As  the  state  of  the  system  has  a  considerable  influence  oft 
the  condition  of  an  ulcer,  so  also  has  the  state  of  the  ulcerative 
action  an  effect  on  the  constitution.  A  healthy  ulcer,  un- 
less very  extensive,  has  little  effect  on  the  system  ;  but, 
unhealthy  ulcers,  or  those  which  are  very  large,  although  the 
action  may  be  sufficiently  perfect,  produce  a  greater  or  less 
degree  of  the  general  diseased  formative  action,  or  what  is 
called  hectic. 

From  the  principles  which  have  already  been  laid  down,  il 
may  easily  be  understoood  how  an  unhealthy  ulcer  should  in 
duce  hectic.  When  considering  the  doctrine  of  suppuration, 
fhe  effects  of  this  on  the  constitution,  or  the  production  & 


a  general  diseased  formative  action  were  attended  to.  It  was 
also  mentioned,  when  considering  ulceration,  that  the  ulce- 
rative action  had  a  tendency  to  produce  similar  effects  ;  and 
this  it  does,  with  a  certainty  proportioned,  caeteris  paribus,  to 
the  unhealthy  condition  of  the  action,  or  its  approximation 
to  the  suppurative  action;  for  the  less  perfect  that  the  ulce- 
rative action  is,  the  more  nearly  does  it  resemble  the  suppu- 
rative one. 

Healthy  ulcers,  if  very  extensive,  produce  likewise  con- 
siderable effects  on  the  constitution.  This  is  chiefly  per- 
haps owing  to  the  purulent  action,  which  makes  a  part  of  the 
ulcerative  one  ;  for  this  morbid  local  secretory  action  in- 
duces a  general  change,  in  the  same  way  as  other  acute 
changes,  of  either  the  formative  action  itself,  or  any  other  in- 
timately connected  with  it,  such  as  the  interstitial.  But, 
besides  this  cause,  the  granulating  action,  although  healthy, 
co-operates  with  the  diseased  interstitial  action,  or  the  pu- 
rulent part  of  the  ulcerative  action;  because,  although  the 
granulations,  or  organic  particles,  be  healthy,  yet  they  are 
formed  in  an  unnatural  situation,  and  with  greater  rapidity, 
and  in  greater  numbers,  in  a  given  time,  than  naturally  they 
ought  to  be ;  and,  therefore*,  the  action  of  the  part  requires 
greater  power  for  its  continuance  than  is  possessed.  There  is 
consequently,  then,  weakness  produced,  which,  by  association 
affects  the  system,  and  co-operates  with  the  diseased  forma- 
tive action,  increasing  the  general  disease.  The  consequence 
of  this  state,  likewise,  is,  that  the  ulcer  comes,  after  some 
time,  to  be  rendered  unhealthy,  owing  to  the  deficiency  of 
power  to  support  the  necessary  action ;  in  which  case,  the 
granulating  action  comes  to  be  also  diseased,  and  co-operates 
still  more  with  the  former  morbid  condition  of  the  interstitial 
vessels  or  the  purulent  action,  which,  although  a  part  of  a 
healthy  ulcerative  action,  is  yet  itself  a  morbid  secretion,  and 
an  unnatural  action. 


97 

The  effects  of  the  ulcerative  action  on  the  constitution,  are 
to  be  alleviated  by  good  diet,  free  air,  and  the  other  reme- 
dies which  have  been  pointed  oat  when  formerly  considering 
hectic,  to  which  I  now  refer.  I  shall  oniy  observe,  that 
some  of  these  remedies  are  employed  occasionally  with  little 
judgment,  and  when  they  are  not  indicated.  It  is,  for  in- 
stance, a  common  practice  with  some,  to  prescribe  the  bark 
for  the  cure  of  every  ulcer,  whether  the  constitution  be  affect- 
ed or  not.  But  from  many  trials,  I  am  confident,  that  it  is  of 
very  little  service,  unless  when  a  general  disease,  whether  it 
be  called  weakness  or  hectic,  exists. 

When  the  proper  remedies  for  the  cure  of  hectic,  con- 
joined with  necessary  local  applications,  fail,  the  diseased 
part  must  be  removed  ;  but,  before  doing  so,  it  is,  in  every 
instance,  proper  to  form  a  pea  issue,  in  order  still  to  keep  up 
a  secretory  action,  the  good  effects  of  which  have  been  al- 
ready noticed. 

The  restlessness,  and  febrile  symptoms,  which  are  some- 
times produced  by  painful  sores,  are  best  relieved  by  ano- 
dynes. 

Of  the  Cure  of  the  Infiammutio  Debilis,  and  the  Treatment 
of  Mortification 

The  causes  and  nature  of  mortification  having  been  alrea- 
dy explained,  I  shall  now  consider  the  means  of  prevention, 
and  the  method  of  cure.  The  remedies  necessary  for  pro- 
curing the  resolution,  or  suppuration  of  the  inflammatio  vali- 
da,  having  been  formerly  enumerated,  it  will  be  unnecessary 
here  to  make  any  repetition,  or  to  say  more  that  that  we  are 
to  prevent  mortification  by  endeavouring  to  induce  one  or 
other  of  the  other  terminations,  and  that  the  remedies  which 
do  so  are  to  be  employed  with  a  promtitude  and  assiduity 
proportioned  to  the  greatness  of  the  action  compared  to  the 


98 

powers  of  the  part ;  and,  therefore,  that  in  the  intestines, 
&c.  we  must  pursue  our  course  speedily,  if  we  expect  to 
prevent  gangrene. 

Mortification,  however,  is  still  more  apt  to  succeed  the  in- 
flammatio  debilis,  or  inflammation  of  weakened  parts  ;  and, 
therefore,  the  treatment  of  this  will  now  more  naturally 
come  to  be  considered,  as  forming  a  part  of  the  prophylaxis 
of  mortification,  than  in  any  other  place. 

The  most  frequent  instance  which  we  have  of  the  inflam- 
matio  debilis,  is  the  inflammation  of  parts  which  have  been 
previously  benumbed  with  cold ;  but  it  may  also  be  produced 
by  the  action  of  any  of  the  common  exciting  causes  of  in- 
flammation, in  weak  and  reduced  habits,  or  by  bruises  in 
sound  parts,  &c. 

When  a  part  has  been  exposed  to  much  cold,  it  may  in- 
flame, from  two  causes:  First,  the  communication  of  action  ; 
secondly,  the  application  of  subsequent  stimulants,  more  es- 
pecially heat.  Both  of  these  tend  to  excite  an  action  in  the 
part,  which  is  greater  than  its  power  would  naturally  per- 
form, and,  therefore,  it  becomes  diseased,  or  inflammation  is 
produced,  and  the  little  energy  which  did  remain  is  soon  de- 
stroyed. The  operation  of  the  first  cause  is  prevented  by 
lessening  the  action  of  the  surrounding  parts,  by  the  applica- 
tion of  moderate  cold,  whilst  we  avoid  motion,  and  whatever 
may  tend  to  act  directly  on  the  part,  and  co-operate  with 
this  cause.  The  operation  of  the  second  cause  is  prevented 
by  keeping  away  every  agent  which  will  tend  to  excite  ac- 
tion, or  at  least  those  which  tend  to  do  so  suddenly.  In  the 
generality  of  cases,  it  is  perhaps  most  proper  at  first  to  do 
nothing ;  because,  whatever  we  apply,  tends  to  excite  a 
greater  action  than  can  be  sustained ;  we  ought,  therefore, 
to  delay  any  remedy  until  the  part  has  begun  to  recover  it- 
self, and  the  action  and  corresponding  power  has  begun  na- 
turally to  increase ;  we  may  then  interfere,  by  applying  such 


99 

remedies  as  increase  the  action,  which  are  perhaps  now  more 
useful,  by  preserving  the  ground  which  is  gained,  than  by 
increasing  still  farther  the  action.  Of  this  kind  is  heat, 
which  must,  upon  this  principle,  be  applied  with  great  cau- 
tion, and  must,  in  its  degree,  be  nicely  adjusted  to  the  exist- 
ing state  of  action.  When  a  part,  then,  is  benumbed  with 
cold,  we  ought  at  first  to  apply  a  degree  of  heat,  very  little 
above  that  which  the  parts  were  formerly  exposed  to,  which, 
in  one  sense,  may  be  said  to  be  doing  nothing ;  for  this  step 
is  intended  merely  to  prevent  farther  injury.  When  this  is 
continued  for  a  short  time,  we  may  suppose  that  the  part  has 
begun  to  act  a  little  more  in  a  natural  way,  which  is  attend- 
ed, as  was  formerly  explained,*  with  a  correspondent  in- 
crease  of  injury*  We  then  increase  the  heat,  but  very 
slowly,  and  taking  a  long  time  to  bring  the  part  near  its 
natural  temperature,  being  regulated  by  the  progress  which 
the  part  itself  is  making ;  for  the  application  of  heat  may  be 
considered  in  two  points  of  view,  in  this  case  ;  first,  as  the 
removal  of  the  injuring  cause ;  and,  secondly,  as  a  stimulus 
to  action.  If,  then,  the  part  do  not  recover  itself,  in  pro- 
portion to  the  removal  of  the  hurtful  cause,  but  remain  sta- 
tionary, it  is  evident  that  a  farther  removal  is  at  present  use- 
less, and  the  stimulus  which  is  consequently  given  is  highly 
dangerous.  By  these  means,  then,  we  proceed  slowly  to- 
ward recovery,  and  keep  up  the  ground  which  we  have 
gained. 

If,  however,  the  action  of  the  part  have  been  sunk  very 
low,  then  recovery  is  impossible,  there  being  little  or  no  en- 
ergy, and  so  little  action,  that  it  cannot  increase  itself  to- 
ward the  natural  state.  In  this  case,  our  endeavours  must 
fail,  and  will  even  kill  the  part  sooner  than  if  we  had  let  it 
alone ;  for  the  least  increase  of  action  destroys  the  life  of 

*  Sec  the  preliminary  dissertation: 

vol;  ft.  x 


100 

the  part,  which  may,  in  this  case,  be  compared  to  a  dying 
taper,  which  gives  one  brighter  flash  before  it  becomes  for 
ever  extinguished. 

If,  on  the  other  hand,  the  action  have  not  originally  been 
sunk  so  low  as  to  make  the  process  toward  death  continue 
progressively,  but  the  remedies  have  been  applied  too  quick- 
ly, or,  from  any  cause,  have  failed  to  produce  this  effect, 
then  the  action  becomes  inflammatory  The  pain  becomes 
of  a  burning  kind,  there  is  a  feeling  of  pulsation,  and  the 
part  becomes  redder,  or  livid,  whereas,  before,  it  was  bluish  ; 
from  the  stagnation  of  the  blood,  there  was  no  feeling  of  pul- 
sation, or  arterial  motion,  and  the  sensation  was  that  of  a 
painful  cold  and  weight.  The  inflammatio  debilis  is  now  in- 
duced, and  the  danger  is  great,  but  still  there  is  a  possibility 
of  recovery,  which  is  exactly  in  proportion  to  the  degree  of 
previous  diminution  of  action,  and  to  the  rapidity  with  which 
the  subsequent  inflammatory  action  was  induced,  and  the 
degree  to  which  it  is  raised ;  or,  in  other  words,  the  danger 
is  proportioned  to  the  disparity  betwixt  the  action  and  the 
power. 

The  remedies  for  this  disease  are  such  as  tend  to  induce 
an  action  similar  to  the  natural  one,  by  which  we  remove  the 
diseased  one ;  for  we  know  of  none  which  excite  the  natural 
action  directly,  otherwise  they  would  be  of  universal  utility, 
and  would,  in  the  present  instance,  be  preferred  to  every 
other.  The  remedies  which  we  employ  with  this  intention, 
are  bark,  opium,  &c.  internally,  and  vinous,  or  spiritous  ap- 
plications externally.  These,  however,  would  be  pernicious, 
were  there  no  inflammation  present,  because  they  would,  by 
exciting  action,  tend  to  induce  this  ;  but,  when  the  inflam- 
matory action  is  once  induced,  then,  as  they  excite  one  more 
nearly  resembling  the  natural  one,  they  are  useful ;  for,  on 
the  one  hand,  they  destroy  the  morbid  one,  and,  on  the 
other,  increase  the  power  of  recovery  ;  but,  for  this  pur- 


101 

pose,  internal  medicines,  and  good  diet,  must  be  given,  as  a 
source  whence  the  energy  is  to  be  renewed,  by  the  renewal 
of  the  natural  action.  Heat  is  of  the  most  pernicious  ten- 
dency in  this  complaint ;  because  it  simply  increases  the 
exciting  action,  and,  therefore,  makes  the  inflammatory  ac- 
tion still  more  violent.  The  applications,  therefore,  ought. 
to  be  cold,  as  long  as  the  morbid  action  continues  ;  but,  when 
it  is  abating,  and  recovery  is  going  forward,  they  may  be 
made  a  little  warmer,  as  they  will  thus  accelerate  the  heal- 
ing process  which  is  taking  place ;  but  this  requires  much 
prudence. 

Spirit  of  wine  is  one  of  the  best  applications  in  this  dis- 
ease, and  is  one  very  generally  employed.  Camphor  is  fre- 
quently added  to  it,  and  appears  to  increase  its  efficacy. 
Pledgets  dipped  in  camphorated  spirit  of  wine,  and  applied 
to  the  part,  will,  if  frequently  renewed,  in  many  cases,  re- 
move the  inflammation,  and  prevent  gangrene  ;  but,  in  every 
instance,  it  at  least  relieves  the  pain,  which  uniformly  re- 
turns, if,  when  the  inflammation  is  violent,  we  omit  the  ap- 
plication, or  use  a  weaker  spirit,  such  as  the  proof  spirit. 

Essential  oils,  particularly  that  of  turpentine,  which  is 
easiest  procured,  are  also  useful,  but  are  inferior  to  the  alco- 
hol. 

Laudanum,  in  slight  cases,  is  useful  as  a  topical  applica- 
tion ;  but,  if  the  inflammation  be  more  severe,  it  must  be 
mixed  with  rectified  spirit.  A  very  useful  application  may 
be  prepared  by  adding  two  ounces  of  laudanum  to  a  pound  of 
the  spt.  vin.  camph.  of  the  pharmacopoeia. 

Internally,  the  bark  must  be  exhibited  in  full  doses,  with 
such  a  quantity  of  wine  as  the  feebleness  of  the  pulse  points 
out ;  but  we  must  be  prudent  in  this  respect,  because,  if  we 
give  too  much,  we  may  increase  the  local  disease.  As  long 
as  it  does  not  increase  the  pain,  or  quicken  the  pulse,  it  is  to 
be  considered  as  useful. 


102 

Opiates  are  extremely  necessary  in  the  inflammatio  debilis, 
and,  in  general,  require  to  be  given  freely. 

Soups,  and  other  articles  of  nourishing  diet,  are  absolutely 
requisite,  and  ought  to  be  given  in  small  quantities  at  a  time, 
but  frequently  repeated. 

By  these  means  we  may  frequently  resolve  the  inflamma- 
tion completely  ;  but,  at  other  times,  when  we  have  gained 
a  certain  ground,  the  inflammation  terminates  in  the  suppura- 
tive action ;  or,  in  other  words,  when  the  parts  have  gained 
more  strength,  and  the  action  has  come  more  nearly  to  resem- 
ble the  inflammatio  valida,  which  has  continued  for  some 
time,  a  similar  termination  takes  place.  This  event  cannot, 
perhaps,  in  these  cases,  be  prevented,  and,  although  it  may 
occasionally  protract  the  cure,  yet  it  diminishes  the  danger, 
making  mortification  less  to  be  dreaded.  The  best  treat- 
ment, in  these  cases,  perhaps,  is  to  continue  our  usual  appli- 
cations, avoiding  warm  poultices  until  the  action  be  fully 
formed ;  then  moderate  heat  may  accelerate  the  progress  of 
the  abscess  toward  the  surface.  The  same  internal  medi- 
cines must  be  exhibited,  the  anodynes,  however,  being 
gradually  diminished  as  the  pain  (which  marks  the  necessity 
for  their  use)  abates. 

It  too  frequently,  however,  happens,  that  either  our  reme- 
dies fail,  or  the  proper  ones  are  not  assiduously  and  judicious- 
ly employed,  in  which  case  mortification  takes  place.  This 
requires  the  same  treatment,  in  whatever  way  it  is  induced, 
only  its  progress  is,  from  certain  causes,  more  rapid*  in  one 
case  ihan  in  another,  and,  therefore  requires  the  more  free 
use  of  the  appropriate  remedies  ;  but  the  general  principle  is, 
in  every  case,  the  same,  and,  therefore,  I  shall  here  consider 
the  disease  indiscriminately,  whether  it  succeeds  the  inflam- 


*  It  is  ..'Ore  rapid  in  the  inflammatio  dobilis  than  in  tbe  inflammatio  valida,  and 
la  very  delicate  parts  than  in  parts  which  are  less  so. 


1Q3 

matio  valida,  or  debilis ;  because,  in  both  instances,  the  case 
is  exactly  the  same,  only,  in  the  first,  the  weakness  which  in- 
duces mortification,  is  produced  by  the  inflammation  alone, 
whereas,  in  the  second,  it  existed  to  a  great  degree  before 
the  inflammation  was  excited. 

Mortification  is  to  be  prevented  from  succeeding  the  in- 
flammatio  valida,  by  timely  bleeding,  and  the  use  of  the 
agentes  dissimiles,  by  which  we  procure  resolution,  or  at 
least  make  the  induction  of  the  purulent  action  more  easy. 
In  the  inflammatio  debilis,  it  is  to  be  prevented  by  remedies 
of  an  opposite  nature. 

When,  however,  these  remedies  fail,  and  mortification 
does  take  place,  our  great  object  must  be  to  prevent  it  from 
extending  far,  and  from  injuring  the  system.  These  inten- 
tions are  answered  by  the  same  remedies  which  cure  the  in- 
flammatio debilis ;  because  the  local  treatment  of  mortifica- 
tion is  merely  that  of  the  inflammatio  debilis  ;  for  it  is  only 
Ihe  parts  which  are  still  alive,  or  inflamed,  which  can  be 
acted  on  by  our  remedies. 

The  remedies  are  either  general  or  topical,  and  may  be 
ronsidered  under  these  divisions ;  but  both  must  be  used  at 
the  same  time. 

Many  of  the  older  writers,  proceeding  upon  the  humoural 
theories,  began  their  treatment  of  gangrene  by  bleeding  and 
purging,  after  which  they  prescribed  theriaca,  and  other  sti- 
mulating applications.  Some  modern  authors  still  adhere, 
in  part,  to  this  practice,  and  consider  the  loss  of  blood  to 
be  advantageous  in  cases  of  incipient  gangrene.  Mr.  Bell, 
who  is  one  of  the  latest  writers  on  this  subject,  informs  us, 
that,  when  the  "  general  symptoms  of  inflammation,  particu- 
larly a  quick,  full,  or  hard  pulse,  still  continue  violent,  and 
especially  when  the  patient  is  young  and  plethoric,  it  then 
becomes  absolutely  necessary,  even  although  mortification 
may  have  commenced,  to  empty  the  vessels  a  little  by  one 


101 

general  blood-letting,"  which,  *  in  such  cases,  may  in  re- 
ality be  considered  as  an  antiseptic  ;  and  it  does  often  in- 
deed, in  this  particular  situation  of  mortification,  prove  more 
powerfully  so,  than  all  the  different  articles  in  general  enu- 
merated as  such."  If,  however,  we  consider  the  nature  of 
mortification,  and  the  circumstances  under  which  it  is  most 
likely  to  occur,  we  must  look  upon  this  practice  as  dange- 
rous, and  must  be  permitted  to  doubt  whether  the  full  hard 
pulse  is  to  be  met  with  after  the  commencement  of  inflam- 
mation, or  whether  the  symptoms  of  the  iuflammatio  valida, 
(in  which  alone  bleeding  is  admissible)  still  continue  violent, 
after  one  portion  of  the  inflamed  part  is  evidently  gangre- 
nous. Is  it  reasonable  to  suppose  that  one  portion  of  the 
inflamed  part  shall  be  already  dead,  or  dying,  and  that  yet 
the  rest  shall  not  have  begun  to  suffer  ?  or  that  the  action 
shall  not  have  become  converted  into  the  inflammatio  debilis, 
(if  it  were  not  originally  this  I)  This  surely  is  not  the  time 
for  bleeding,  purging,  and  debilitating  remedies ;  but  the 
part  must  be  considered  as  possessing  the  low  inflammatory 
action,  and  the  patient  as  requiring  suitable  remedies.  It 
may  indeed  be  said  by  some,  in  favour  of  bleeding,  that  the 
bark,  in  some  instances,  does  not  check  the  progress  of  the 
disease ;  but  it  surely  does  not  thence  follow,  that  it  does 
positive  injury,  and  that  remedies  of  an  opposite  nature  are 
useful. 

The  peruvian  bark  is,  in  many  cases,  one  of  the  most  use- 
ful internal  remedies.  It  was  originally  introduced  into  me- 
dicine, about  one  hundred  and  fifty  years  ago,  as  a  cure  for 
intermittent  fever  ;  and  its  utility  in  gangrene  is  said  to  have 
been  discovered  by  its  curing  this  disease  in  a  person  who 
had  it  combined  with  ague,  and  who  was  taking  the  bark  on 
account  of  the  latter  complaint.  For  many  years  after  it 
was  known  in  Europe,  great  prejudices  prevailed  among  phy- 
sicians against  its  use,  partly  on  account  of  its  having  been 


105 

improperly  administered,  but  still  more  because  it  was  so  un- 
fortunate as  to  cure  diseases  without  necessarily  either 
sweating  or  purging  the  patient,  a  fact  which  could  be  only 
ill  explained,  or  rather  scarcely  allowed  to  be  possible,  by 
the  prevailing  theories  of  physic.  Accordingly,  although 
the  cases  in  which  it  had  been  successful  were  by  no  means 
a  secret,  and  although  several  had  the  courage  to  employ  it, 
in  spite  of  all  speculative  arguments,  yet  neither  Dr.  Boer- 
haave,  nor  his  commentator,  Van  Swieten,  thought  it  expe- 
dient either  to  recommend  or  prescribe  it.  Renewing  the 
motion  of  the  stagnating  blood  by  venesection,  and  the  ex- 
hibition of  trifling  remedies,  which  could  scarcely  be  called 
cordial,  although  sometimes  dignified  with  that  epithet,  to- 
gether with  the  external  application  of  ardent  spirits,  or  oil 
of  turpentine,  constituted  the  current  practice  in  gangrene. 
These  prejudices  against  the  bark,  which  originated  in  igno- 
rance, and  were  supported  by  attention  to  a  foolish  theory, 
continued  long ;  but  the  want  of  a  better  remedy  began  at 
last  to  make  them  gradually  give  way,  and  the  success  of 
empyrics  who  used  the  bark  soon  completed  their  downfall. 
The  bark  induces  an  action  nearly  similar  to  the  natural 
one,  which  is  greatly  injured,  and,  therefore,  it  gives  a  check 
to  the  progress  of  the  disease ;  but,  if  its  operation  be  not 
assisted  by  nourishment,  £cc.  its  good  effects  soon  subside, 
because  the  materials  whence  new  energy  can  be  drawn  are 
withheld,  and,  therefore,  the  system  cannot  profit  so  much 
by  the  establishment  of  the  new  action,  and  by  the  restora- 
tion of  the  power  of  converting  the  vital  principle  of  foreigu 
matter  into  nervous  energy.  The  bark,  then,  is  of  service, 
in  two  points  of  view:  First,  it  changes  directly  the  action 
of  the  system,  it  induces,  in  a  considerable  degree,  an  action 
somewhat  similar  to  the  natural  action,  and,  therefore,  coun- 
teracts the  general  action  of  descent  which  was  taking  place. 
Secondly,  by  inducing  this  action,  it,  to  a  certain  decree* 


J  06 

produces  the  same  effects  for  a  time  which  would  have  been 
produced  by  the  natural  action  itself,  or  increases  the  power 
of  renewing  vitality ;  for,  in  the  preliminary  dissertation,  it 
was  mentioned,  that  the  production  of  energy  was  exactly 
proportioned  to  the  perfection  and  healthiness  of  the  exist- 
ing action.  The  good  effects  of  bark,  then,  cannot  be  ob- 
tained without  nourishment  and  free  air. 

It  uniformly  happens,  however,  that,  in  many  instances, 
where  the  action  of  the  bark  would  be  most  beneficial,  it  is 
impossible  to  induce  it,  owing  to  several  causes,  but  particu- 
larly to  its  effect  on  the  stomach ;  for,  in  many  instances,  it 
produces  sickness,  or  nausea,  in  which  case  it  can  do  no 
good,  and  ought  to  be  abandoned.  Momentary  sickness, 
after  taking  a  dose  of  bark,  is  indeed  a  very  general  effect, 
and  does  not  materially  injure  its  operation ;  but,  whenever 
it  is  either  frequently  vomited,  or  produces  a  sickness  of 
considerable  duration,  it  must  either  be  given  in  smaller 
quantities,  or  in  a  different  form,  or  at  longer  intervals ;  or 
if  all  of  these  fail,  it  must  be  laid  aside  completely,  because 
it  not  only  cannot  produce  its  specific  effect,  but  will  even 
injure  the  remaining  powers  by  its  effect  upon  the  stomach. 

The  best  form  in  which  bark  can  be  prescribed  is  that  of 
powder,  which  is  more  effectual  than  any  tincture,  or  the 
extracts.  This  ought  to  be  exhibited  in  as  great  quantity 
as  the  stomach  will  bear,  which  cannot  be  reduced  to  any 
certain  scale.  In  general,  an  adult  ought,  if  possible,  to  take 
half  a  drachm,  or  two  scruples,  every  forty  minutes,  in  the 
most  palatable  vehicle ;  for  much  depends  upon  the  taste, 
owing  to  the  sympathy  betwixt  the  mouth  and  the  stomach  ; 
and,  for  this  reason,  the  same  vehicle  ought  seldom  to  be 
used  more  than  twice  in  immediate  succession  ;  because,  by 
changing  the  vehicle,  we  not  only  change  the  taste,  which 
has  a  tendency  to  prevent  loathing,  but  also  modify  the  im- 
mediate action  on  the  stomach,  changing,  to  a  certain  degree^ 


107 

the  former  impression,  which  was  perhaps  beginning  to  pro- 
duce sickness.  Lemon  juice  and  water,  the  different  kinds 
of  wines,  punch,  pimento,  cinnamon,  and  peppermint  waters, 
milk,  rose  water,  beer,  &c.  afford  us  a  variation  which  may 
be  usefully  employed. 

The  tincture  and  watery  infusion  of  the  bark,  either  se- 
parately or  mixed  together,  are  frequently  employed,  when 
the  powder  is  vomited ;  but,  as  they  must  be  given  in  very 
considerable  quantities,  in  order  to  produce  any  good  effect, 
they  are  very  apt  to  produce  sickness,  and  are  likewise  so 
inferior  in  power  to  the  powder,  that  they  are  very  little  to 
be  trusted. 

The  extract  with  resin,  is  a  better  form  than  the  tincture, 
or  infusion  ;  and,  where  the  powder  is  rejected,  may  be 
made  into  pills. 

When  the  stomach  rejects  every  form  and  preparation,  it 
has  been  proposed  to  give  the  bark  in  clysters,  and  this 
ought  certainly  to  be  done  rather  than  lose  the  effects  of  the 
remedy  ;  but,  ,given  in  this  way,  its  effects  are  more  uncer- 
tain. From  two  drachms  to  half  an  ounce  of  the  powder  of 
bark,  may  be  diffused  in  three  ounces  of  soup,  or  mucilage, 
with  fifteen  or  twenty  drops  of  laudanum,  and  given  as  an 
enema.  This  must  be  repeated  at  least  every  hour  and  a 
half,  or  two  hours,  until  the  stomach  can  retain  the  medir- 
cine. 

The  wine  is  very  usefully  conjoined  with  the  bark,  and  is 
even  of  considerable  use  by  itself,  when  the  bark  is  reject- 
ed. Its  operation  is  more  speedy  than  that  of  the  bark, 
but  it  is  perhaps  more  fugacious.  The  quantity  which  is 
necessary  to  be  given  depends  upon  the  effect  of  the  local 
disease  upon  the  system,  and  on  the  inability  to  bear  other 
remedies.  A  table  spoonful  may  be  given  in  general  every 
quarter  of  an  hour,  unless  it  increase  the  pain,  and  frequency 
of  pulse,  and  produce  restlessness,  and  heat  of  $e  skhi.     Tn 

Tol,  n.  o 


108 

these  circumstances,  we  may  be  certain  that  we  have  in- 
creased the  quantity  beyond  the  necessity.* 

Opium  is  likewise  an  useful  remedy  in  this  disease,  and 
ought  never  to  be  omitted ;  because  it  not  only  diminishes 
the  irritability,  and,  consequently,  the  pain,  but  likewise, 
like  the  wine  and  the  bark,  counteracts,  by  the  induction  of 
its  peculiar  action,  the  progress  of  the  inflammatio  debilis, 
and,  consequently,  tends  to  check  the  mortification.  This 
medicine  is  most  usefully  exhibited  in  full  doses,  which  not 
only  procure  ease,  but  also  frequently  make  the  stomach 
more  readily  bear  other  remedies.  One  grain  of  the  extract, 
or  twenty-five  drops  of  the  tincture,  may  be  given  at  once, 
and  the  dose  repeated  whenever  the  action  of  the  former 
subsides.  After  some  time,  each  dose  must  be  increased 
one  half,  and  presently  doubled,  in  order  to  produce  the 
same  effect  as  it  did  at  first. 

These  remedies  may  give  a  temporary  check  to  the  dis- 
ease ;  but,  unless  nourishment  be  conjoined,  in  every  possi- 
ble form,  they  will  not  of  themselves  be  able  to  effect  a 
cure,  if  the  disease  be  tedious.  Soups,  jellies,  milk,  sago, 
&c.  must  be  assiduously  given  in  small  quantities,  and  eveu 
thrown  up  as  clysters,  if  the  stomach  cannot  bear  them. 

Vegetable  acids,  fixed  air,  wort,  &c  have  been  recom- 
mended in  this  disease,  probably  upon  the  supposition  of  the 
existence  of  a  putrescent  matter,  or  from  their  utility  in 
scurvy.  Wort,  however,  and  fixed  air,  do  not  appear  to  be 
of  very  great  benefit  in  this  disease,  at  least  they  are  by  no 
means  to  be  put  in  competition  with  other  remedies  of  more 
approved  efficacy,  or  allowed  to  interfere  with  their  exhibi- 
tion.    The  acid  of  lemons  seems  to  be  more  generally  useful 


*  The  necessity  for  this,  and  other  remedies,  is  in  general  proportioned  to  the 
continuance  of  the  disease,  and  the  progress  which  it  has  made.  In  this,  as  in. 
every  other  disease,  we  must  be  attentive  to  the  effects  of  oot  remedies,  and  con- 
sider these  in  forroiog  ouropiffjen.- 


10$ 

than  the  carbonic  acid ;  and,  perhaps,  the  nitrous  acid 
would  be  equally  useful  with  the  citric  acid.  These  acids 
do  not  operate  by  counteracting  putrefaction,  but  by  coun- 
teracting' the  action  of  descent,  inducing  a  more  healthy 
action,  and  tending  to  excite  ulceration,  which  is  the  mean 
employed  for  separating  the  dead  part,  and  producing  re- 
storation. For  this  purpose,  however,  the  acids  must  be 
given  freely,  otherwise  no  good  is  done. 

The  local  treatment  is  to  be  conducted  on  the  same  prin- 
ciple as  in  the  cure  of  the  inflammatio  debilis.  Pledgets, 
dipped  in  the  oil  of  turpentine,  tincture  of  myrrh,  or  rather 
in  camphorated  spirit  of  wine,  which  is  one  of  the  best  ap- 
plications which  can  be  used,  ought  to  be  made  use  of. 

These  remedies  can  do  little  service  when  applied  to  the 
dead  portion ;  but,  as  the  whole  part  does  not  die  at  once, 
there  are  always  some  portions  which  are  still  in  the  inflamed 
state,  and  on  which  they  act.  They  likewise  prevent  the 
progress  of  the  disease,  by  operating  on  the  skin  which  is 
contiguous  to  the  gangrene.  Every  mortification,  in  gene?' 
ral,  attacks  the  skin  first ;  or,  in  other  words,  the  inflamma- 
tio debilis  spreads  faster  along  the  skin  than  along  the  deeper 
parts ;  but,  when  once  the  skin  is  inflamed,  and  mortifies, 
the  disease  extends  to  a  greater  or  less  depth  below  the  sur- 
face. Whatever,  then,  operates  on  the  surface,  and  pre- 
vents the  progress  of  the  inflammation,  or  cures  the  part 
which  is  already  inflamed,  will  tend  to  check  the  extension 
of  the  disease,  especially  if  the  proper  internal  remedies  be 
made  use  of  with  a  view  to  prevent  the  extension  of  the  ac- 
tion of  descent. 

Formerly,  in  order  to  allow  these  remedies  to  come  in  con- 
tact with  the  living  parts,  it  was  customary  to  make  incisions 
through  the  dead  portion,  and  not  unfrequently  through  part 
of  the  living  substance.  But  as  these  cannot  prevent  the 
extension  of  the  disease  over  a  greater  surface,  and,  as  the 
irritation  which  is  given,  and  the  exposure  of  parts  which 


110 

have  not  yet  assumed  the  ulcerative  action,  tend  to  increase 
the  inflammatio  debilis,  the  practice  must  be  considered  as 
improper. #  It  is  now  indeed  almost  universally  laid  aside, 
owing,  in  a  great  measure,  to  the  observations  of  the  ingeni- 
ous Mr.  Pott. 

Antiseptics,  such  as  decoction  of  camomile  flowers,  &c. 
have  been  recommended  as  external  applications  ;  but,  what- 
ever effects  they  may  have  on  the  matter  which  is  already 
dead,  it  is  evident  that  they  can  be  of  no  service  in  preserv- 
ing the  living  parts  from  suffering  death.  All  that  can  be 
expected  from  them  is  to  check  the  putrefaction  of  the  dead 
substance,  which  they  have  very  little  power  to  do  ;  and, 
therefore,  they  can  never  come  into  competition  with  more 
valuable  remedies,  such  as  the  camphorated  spirit  of 
wine,  &c. 

W  hen,  by  the  use  of  the  remedies  already  mentioned,  the 
progress  of  the  gangrene  is  stopped,  the  ulcerative  action  is 
induced  in  the  part  immediately  adjoining  to  the  dead  portion, 
and  a  red  line  of  separation  appears.  By  means  of  this  ulce- 
rative action,  which  takes  place  in  every  point  where  the 
mortification  stops,  the  dead  part  is  separated  from  the  liv- 
ing, and  comes  away  as  soon  as  the  bonds  of  dead  muscular 
fibres,  tendons,  &c.  which  unite  them,  are  destroyed  by  pu- 
trefaction. When  this  separation  takes  place,  or  when  it  is 
advanced  so  far  as  to  permit  us  to  accelerate  it  by  dividing 
the  loose  tendons,  vScc.  the  exposed  part  must  be  dressed  as  an 
ulcer,  or  wrapped  up  in  a  poultice  of  the  same  temperature 
with  the  human  body. 

If,  however,  the  disease  have  penetrated  deep,  and  destroy- 
ed the  limb  so  much  as  to  render  it  impossible  to  cure  it,  or 
useless,  if  it  were  possible,  then  amputation  must  be  perform- 


*  The  hot  and  almost  boiliug  oil?,  which  were  poured  into  these  Incision?,  cbii- 
tributed  not  a  little  to  increase  the  disease. 


Ill 

-ed;  but  this,  whatever  desire  the  patient  may  express,  must 
not  be  practised  until  the  mortification  be  fully  stopped,  and 
the  ulcerative  action  induced ;  because  if  performed  sooner, 
the  mortification  seizes  the  stump,  and  the  patient  is  quickly 
killed.  The  system  is  likewise  in  such  a  state  as  to  be  una- 
ble to  sustain  the  action  which  is  necessarily  produced  by 
the  operation.  It  is  even  improper  to  cut  too  near  the  dis- 
eased portion;  because  the  parts  here,  although  the  mortifi- 
cation be  stopped,  are  so  weakened,  that  they  are  less  apt  to 
unite.  The  vessels  often  break  out  soon  after  they  are  tied, 
and  a  new  mortification  is  by  no  means  an  unlikely  occur- 
rence. Even  when  the  amputation  is  performed  pretty  far 
up  the  limb,  the  corners  of  the  stump  frequently  mortify,  or 
become  livid;  but  a  few  doses  of  bark  and  wine  stop  the  pro* 
gress  of  the  disease. 

Although  it  is  a  general  rule  that  amputation  is  necessary 
whenever  the  member  is  so  destroyed  as  to  become  useless, 
and  although  this  must  not  be  performed  until  the  ulcerative 
action  be  induced,  yet  it  must  not  invariably  be  performed, 
whenever  this  action  takes  place,  because  sometimes  at  this 
period  the  patient  is  unable  to  sustain  the  general  action 
which  the  operation  would  produce.  We  must,  therefore, 
if  the  patient  be  much  reduced  by  the  extent,  or  long  con- 
tinuance of  the  disease,  rather  delay  until,  by  good  diet, 
wine,  &c.  we  have  procured  an  increase  of  strength ;  but,  if  we 
find  that  either  the  patient  loses  ground,  or  his  weakness  re- 
mains stationary  under  this  treatment,  we  must  then  ampu- 
tate ;  because,  it  is  probable,  that  the  continuance  of  the 
dead  portion  in  contact  with  the  living  is  tending  to  induce 
still  the  general  action  of  descent.* 


*  As  an  illustration  of  this  rule,  I  may  mention  the  following  case :  A  man,  du- 
ring a  voyage  to  a  cold  climate,  had  both  his  feet  frost-bit,  in  consequence  of 
which  mortification  ensued.  In  this  state  he  continued  for  two  or  three  weeks,  du- 
ring which  he  received  very  little  medjeal  aid.    When  I  saw  him,  both  his  feet 


112 

When  we  do  not  deem  it  advisable  to  amputate  Very  soon 
after  the  induction  of  the  ulcerative  action,  it  is  sometimes 
useful  to  cut  off  part  of  the  black  mortified  portion,  or  per- 
haps to  remove  a  joint,  by  cutting  through  the  remaining 
ligaments.  In  this  way,  we  lessen  the  fcetor,  and  make  the 
patient  more  comfortable. 

After  making  these  observations  on  mortification,  I  shall 
conclude  with  the  following  case : 

A  young  woman,  who  lived  at  a  considerable  distance  from 
Glasgow,  was  in  May  1797,  seized  with  erysipelas  of  the  right 
foot  and  leg,  which,  by  her  account,  had  been  extremely 
violent,  and  very  much  neglected.  On  the  tenth  day  of  the 
disease  she  was  brought  to  town,  and  admitted  into  the  hospi- 
tal. The  foot  was  quite  cold,  the  leg  livid,  and  extremely 
painful.  Pledgets  dipped  in  camphorated  spirit  of  wine, 
were  applied  to  the  parts,  and  bark,  wine,  and  opium, 
were  prescribed,  together  with  oranges,  &c.  and  gradu- 
ally increased  in  quantity,  until  at  last  she  came  to  drink* 
besides  soup,  a  couple  of  bottles  of  wine  daily,  at  the  same 
time  that  she  took  eight  grains  of  opium,  and  a  very  consi- 
derable quantity  of  bark,  in  the  twenty -four  hours.  By  these 
means,  the  pulse  was  soon  brought  down  from  one  hundred 
and  forly  to  one  hundred  and  eighteen  strokes  in   the  mi- 

<»cre  mortified,  from  the  toes  to  about  three  indies  above  the  ankle  joints,  his  pulse 
Tvas  feeble,  very  frequent,  and  intermittent,  the  strength  was  greatly  impaired,  and 
Mie  countenance  sunk  and  ghastly.  The  ulcerative  action  had  been  induced 
;'or  some  time,  but  the  want  of  wine  and  proper  diet  had  prevented  the  system 
from  gaining  by  the  cessation  of  the  local  disease.  He  began  the  use  of  the  bark, 
opium,  wine,  and  soups,  which  he  took  very  liberally,  in  consequence  of  which  his 
nulse  became  slower,  and  his  strength  increased.  In  two  days,  one  of  the  ankle 
.joints  was  removed  by  clipping  through  the  tendons,  and,  in  a  few  days  more,  the 
rtther  came  away.  Amputation  was  now  performed  below  the  knee  of  the  right 
leg,  the  constitution,  instead  of  gaining,  rsther  beginning  to  lose  ground.  The 
subsequent  affection  of  the  system  was  by  no  means  great,  and,  in  about  a  week, 
he  was  much  stronger ;  but,  as  the  bones  of  the  ankle  joint  of  the  other  leg  were  ca- 
:ious,  he  again  began  to  sink.  Amputation  was  therefore  performed  on  the  left 
side,  in  about  three  weeks  after  the  first.  During  the  cure,  the  wine,  opium,  and 
Nourishing  diet,  were  freely  prescribed. 


113 

uute ;  but  it  was  not  until  twenty  days  after  her  admissioti 
that  the  ulcerative   action  was  evidently  induced.      The 
quantity  of  the  medicine  was  now  gradually  diminished  ;  and,, 
in  a  few  days  more,  the  separation  being  complete,  the  limb 
was  amputated  above  the  knee.     During  the  operation,   I 
paid  particular  attention  to  the  saving  of  blood ;  and  the  cir- 
culation being  destroyed  in  the  parts  below  the  knee,  there 
was  scarcely  any  lost;     At  this  time,  she  was  still  taking  a 
bottle  of  wine,   with  a  considerable  quantity  of  bark  and 
opium,  daily.    The  wine  was  omitted  after  the  operation ;  but 
she  had  a  drachm  of  laudanum,  and  continued  to  take  the  bark. 
In  the  evening  the  same  quantity  of  laudanum  was  repeated. 
Next  day  she  was  quite  easy,  and  had  slept  well ;  the  pulse 
beat  only  one  hundred  in  the  minute.     On  the  third  day 
the  stump  was  dressed,  when  it  was  found  ^as  was  to  be  ex- 
pected,*) that  only  a  very  imperfect  adhesion  had  taken 
place :  One  of  the  corners  was  also  livid.     The  bark  was 
therefore  freely   continued,  and  six  ounces  of  wine  added 
daily ;  but  the  pulse  having,  on  the  fifth  day,  risen  to  one 
hundred  and  ten,  and  the  spot  becoming  of  a  darker  colour, 
she  was  allowed  a  pound  of  wine,  which  made  the  pulse  falf, 
and  soon  produced  a  separation  of  a  small  slough.     In  a 
short  time  she  went   to    the  country  cured.     During  the 
whole  period  of  the  cure,  the  opium  and  wine  which  she 
took  produced  neither  stupor,  nor  the  slightest  appearance 


*  It  is  very  seldom  that  a  stump  unites  at  first,  if  amputation  be  performed  oo 
account  of  mortification  ;  at  least  if  the  operation  be  not  delayed  until  the  health^ 
and  strength  be  fully  re-established  :  But  this  can  very  seldom  be  the  case  ;  for, 
in  most  cases,  the  state  of  tke  bones,  and  the  disease  of  the  part  itself,  prevents 
recovery  from  taking  place  beyond  a  certain  degree,  and  also  prevents  us  from 
delaying  beyond  a  limited  time.  The  system,  therefore,  is  not  allowed  to  recovf  i 
fully  from  the  tendency  to  the  action  of  descent,  and  union  does  not  take  place 
In  the  case  which  was  formerly  mentioned,  the  first  stump  did  not  adhere  fully, 
but  the  second  succeeded  better,  because  then  the  system  suffered  more  from  the 
state  of  the  diseased  bones,  &c.  than  from  the  previous  mortification,  and,  there- 
fore, it  had  not  the  same  inability  to  undergo  the  healing  action-., 


114 

of  intoxication.  I  at  one  time,  when  the  pain  had  for  a  cou- 
ple of  days  been  moderate,  was  willing  to  ascertain  the  ef- 
fects of  a  milder  preparation  than  the  camphorated  spirit, 
and  substituted  proof  spirit  in  its  place ;  but,  in  an  hour,  it 
was  obliged  to  be  renewed,  the  pain  having  greatly  increased. 

Of  the  Treatment  of  the  Injiammatio  Assuefacta. 

After  the  inflammatio  valida  has  continued  for  a  considera- 
ble time,  if  neither  suppuration,  nor  any  other  termination 
be  induced,  it  is  very  apt  to  be  converted  into  the  state 
which  has  been  called  passive  inflammation,  or  which,  on  ac- 
count of  its  most  frequent  cause,  I  have  called  the  inflam- 
matio assuefacta.  This  action  is,  in  several  respects,  dif- 
ferent from  the  acute  inflammation,  and  resembles  it  only  in 
its  general  appearance.  It  may,  therefore,  in  one  respect,  be 
considered  as  a  termination  of  inflammation,  being,  strictly 
speaking,  a  new  action,  or  spurious  inflammation. 

This  action  succeeds  the  acute  inflammation,  sooner  or 
later,  in  different  places ;  and,  when  once  induced,  each  suc- 
ceeding inflammation  of  the  same  part  is  apt  very  quickly  to 
terminate  in  the  same  condition  ;  or,  if  the  renewal  of  the 
inflammation  be  very  frequent,  this  is  at  last  induced  with- 
out any  previous  acute  inflammation. 

A  state  somewhat  similar  to  this,  if  not  exactly  the  same, 
precedes  acute  inflammation,  as  well  as  follows  it ;  for,  during 
the  period  which  intervenes  betwixt  the  first  formation  of 
the  action  and  its  perfection,  the  part  remains  in  this  state. 
We  can  sometimes  observe  the  augmentation  and  diminution 
of  the  redness  and  pain  during  the  systole  and  diastole  of 
the  arteries ;  and,  by  the  use  of  the  same  remedies  which 
cure  the  inflammatio  assuefacta,  we  can  sometimes  prevent 
the  farther  progress  of  the  disease. 


116 

Thus,  pepper  boiled  in  milk,  is  frequently  used  by  the 
country  people  as  a  cure  for  cynanche,  during  its  incipient 
stage. 

Bleeding,  saturnine  applications,  and  the  other  remedies 
which  are  useful  in  the  inflammatio  valida  et  acuta,  are 
hurtful  here,  and  increase  the  disease. 

The  agentes  similes,  on  the  contrary,  are  useful,  and  may 
be  used  internally,  or  topically. 

Internally,  the  bark,  wine  and  opium,  with  good  diet, 
ought  always  to  be  employed,  if  the  part  affected  be  very 
delicate,  and  sympathize  greatly  with  the  constitution,  or  if 
the  extent  of  the  disease  be  great. 

Locally,  stimulating  applications  are  the  proper  remedies  ; 
and  the  strength  and  nature  of  these  must  depend  upon  the 
natural  or  acquired  delicacy  of  the  part. 

When  the  skin,  or  cellular  substance,  is  affected  with  the 
inflammatio  assuefacta,  spirit  of  wine  by  itself,  or  with  the 
addition  of  a  little  camphor,  is  a  very  useful  application. 

When  the  skin  is  not  directly  affected,  but  only  the  parts 
immediately  below  it,  as,  for  instance,  the  muscles  in  chronic 
rheumatism,  or  the  articulating  surfaces  of  joints,  we  may 
sometimes,  by  applying  cloths  dipped  in  laudanum,  or  strong 
diffusion  of  opium,  propagate,  from  the  surface  to  a  certain 
distance,  the  narcotic  action,  and  alleviate  the  disease  ;  but, 
most  frequently,  we  are  obliged  to  trust  entirely  to  the  ef- 
fect of  the  sympathy  of  equilibrium,  diminishing  the  action 
of  the  internal  parts,  without  any  considerable  change  of  na- 
ture, by  increasing  that  of  the  surface.  Blisters  and  rube- 
facients, such  as  volatile  linamentol.  terebrinth.  cum  cam- 
phora,  &c.  are  the  remedies  for  this  purpose. 

The  inflammatio  assuefacta,  when  it  affects  delicate  parts, 
covered  only  with  a  thin  skin,  such  as  the  throat,  forming 
one  of  the  most  frequent  species  of  cynanche,  is  cured  by 

VOL.    II.  p 


116 

gargling  with  port  wine,  infusion  of  capsicum,  and  similar  re- 
medies. 

When  it  affects  the  eyes,  the  use  of  stimulating  and  opia- 
ted preparations  have  been  long  in  use.  The  following  is 
one  of  the  best : 

R.  Vini  Albi  uncias  duas. 
Opii  drachmam. 

Pulv.  Gall,  scrupulum.      Macera  per  dies  tres  dein 
cola. 

A  drop  or  two  of  this  may  be  let  fall  into  the  eye  three 
times  a  day. 

Electricity  is  recommended  in  the  cure  of  this  kind  of 
inflammation ;  but  this,  as  well  as  heat,  are  doubtful  reme- 
dies ;  for  both  seem  to  increase  actions  without  changing 
them,  except  in  so  far  as  the  change  depends  upon  an  in- 
creased degree.  Cold,  on  the  other  hand,  lessens  the  power 
of  recovery,  if  carried  to  any  great  degree  ;  but,  when  slight, 
it  assists  the  operation  of  other  remedies,  by  lessening  the 
performance  of  the  existing  action,  which  is  morbid.  All 
applications,  therefore,  ought  in  general  to  be  a  little  below 
the  temperature  of  the  part. 

Whenever  an  inflammation  does  not  manifest  a  tendency 
to  any  other  termination,  but  continues  stationary,  or  per- 
haps becomes  worse,  under  the  use  of  the  remedies  which 
we  employ  for  the  cure  of  the  inflammatio  valida,  we  may 
consider  that  this  action  (or  the  inflammatio  assuefacta)  has 
taken  place,  and  that  the  nature  of  our  applications  must  be 
changed.  Bark  and  wine,  with  anodynes,  may  be  given  in- 
ternally, whilst,  if  the  situation  of  the  part  permit,  suitable 
applications  must  be  made  to  it.  By  continuing  this  treat- 
ment, we  frequently  resolve  the  inflammatio  assuefacta  ;  but, 
occasionally,  it  becomes  again  converted  into  the  true  acute 


117 

inflammation,  in  which  case  the  continuance  of  the  same  re- 
medies will  do  hurt.  The  appropriate  local  remedies,  such 
as  cold,  saturnine  preparations,  &c.  must  be  had  recourse  to, 
if  the  part  be  external,  whilst,  if  the  pulse  become  hard,  and 
more  frequent,  or  fuller,  general  remedies,  such  as  bleeding 
in  small  quantity,  may  be  useful ;  but  both  local  and  general 
remedies  must  be  used  with  moderation,  and  pushed  only  a 
certain  length,  otherwise  we  defeat  our  intention,  and  again 
speedily  induce  the  inflammatio  assuefacta,  by  interfering 
with  the  powers  of  recovery.  If  this  happen,  we  must 
again  have  recourse  to  the  proper  remedies. 


DISSERTATION  III. 


ON    THE    PHAGEDENIC,    AND    SOME    OTHER    SPECIE?    OF 
SPECIFIC    INFLAMMATION. 


When  any  peculiar  modification  of  the  inflammatory  action 
takes  place,  specific  inflammation  is  said  to  be  produced  ; 
that  is  to  say,  the  action  possesses  some  peculiar  or  specific 
qualities,  independent  of  the  simple  condition  of  inflamma- 
tion ;  and  these  are  generally  productive  of  evident  and  vi- 
sible effects,  which  are  characteristic  of  their  presence  ;  but, 
until  these  effects,  which  are  chiefly  observable  in  the  ap- 
pearance of  the  consequent  ulceration,  appear,  it  is  frequent- 
ly impossible,  from  the  symptoms  of  the  inflammation  alone, 
to  say  that  it  is  specific  ;  because  the  evident  effects,  or 
symptoms  of  the  inflammatory  action,  such  as  heat,  pain, 
redness,  Stc.  admit  of  few  specific  alterations,  varying  only 
in  degree,  and  this  variation  taking  place  often  without  any 
specific  affection  of  the  action.'* 

The  effects  of  the  ulcerative  action  admit  of  greater  varia- 
tions than  those  of  the  inflammatory,  and,  therefore,  more  rea- 
dily show  the  presence  of  specific  action.  The  healthy  ulcera- 
tive action  exhibits  certain  appearances  which  have  been  al- 


*  In  most  specific  inflammations-,  if  not  in  every  one,  the  redness  is  never  of  the 
bright  scarlet  colour,  but  always  more  or  less  purple,  or  dusky  ;  but  this  m?'. 
take  place  without  any  specific  action.    The  sensatioD  is  also  sometimes  different 


119 

ready  described,  and  which  are  easily  known.    The  simple  de- 
viations which  have  been  treated  of,  in  considering  the  differ- 
ent genera  of  ulcers,  are  also  discoverable  by  the  effects,  or 
peculiar  symptoms.     The  specific  deviations  dependent  upon 
the  presence  of  previous  specific  inflammation,  or  the  appli- 
cation of  a  morbid  agent,  after  simple  ulceration  has  been  in- 
duced, may  also,  in  many  cases,  be  detected  and  ascertained, 
by  the  variations  which  take  place  in  the  aspect  of  the  sore, 
the  appearance  of  the  granulations,  discharge,  &c. ;  but  these 
variations  and  appearances  consist  so  much  in  peculiar  hues 
and  qualities  of  the  granulations,  which  we  have  no  Words  to 
convey  an  idea  of,  that  it  is  impossible  to  give  an  accurate 
description  of  a  specific  sore,  but  must  see  it  in  order  to 
obtain  an  idea  of  it.     We  may  indeed  say,  that  a  sore  is 
ragged,  has  a  fiery  look,  is  surrounded  with  an  erysipelatous 
margin,  and  discharges  a  thin  foetid  matter,  but  still  we  shall 
not  convey  the  idea  of  the  specific  appearance  of  the  ulcer. 
It  is  this  specific  appearance  alone  which  characterizes  a 
specific  ulcer  ;  and  this,  in  each  peculiar  ulcer,  is  different ; 
and  a  knowledge  of  it  can  only  be  obtained  by  an  attentive 
examination  of  many  sores.     On  this  account,  it  is  extreme- 
ly difficult,  in  many  instances,  to  distinguish  a  specific  ulcer, 
because  the  discrimination  depends  altogether  upon  the  re- 
rollection  of  the  practitioner,  and  the  improvement  which 
he   has  made  of  his  former  observations.     It  is  indeed,  it 
may  be  thought,  an  easy  matter  to  distinguish  a  simple  ulcer 
by  negative  characters,  or  the  want  of  the  peculiar  aspect ; 
but,  as  this  aspect  is  very  arbitrary,  and  as  the  appearance 
of  simple  ulcers  is,  as  has  been  already  described,  very  va- 
rious, it  is  difficult  to  say,  without  much  judgment,  whether 
the  sore  be  simple  or  specific  ;  for  the  appearance  of  the  one 
and  of  the  other  run  imperceptibly  into  each  other.     Even 
it'  it  be  ascertained  to  be  specific,  it  is  difficult  often  to  dis- 
tinguish betwixt  particular  specific  diseases,  in  so  much,  that 


120 

many  are  forced  to  take  mercury  for  the  cure  of  syphilis, 
who  never  had  that  disease. 

Besides  the  appearance  of  the  sores,  specific  action  like- 
wise produces  a  perceptible  effect  upon  the  scab  which 
covers  them,  or  the  cicatrix  which  is  formed.  Thus,  scro- 
phula  is  marked  by  a  particular  appearance  of  the  cicatrix, 
or  of  the  scab.  The  venereal  ulcer  has  likewise  a  particular 
scab,  and  many  cutaneous  ulcers  are  best  distinguished  by 
the  scab.  Other  actions  produce  no  considerable  ulcera- 
tion, but  only  successive  desquamation  of  the  cuticle. 

We  may  also  sometimes  discover  specific  action  by  the 
sensation  of  which  the  action  is  productive.  Thus,  for  in- 
stance, cancer  produces  a  burning  kind  of  pain,  which  never 
attends  simple  ulceration. 

Specific  ulceration  is  also  always  surrounded  with  more 
or  less  simple  inflammation,  or  erysipelas,  of  the  surrounding 
skin.  In  some  cases  the  margin  is  hard,  in  others  ragged, 
.Sec. 

It  were  much  to  be  wished,  that  some  more  certain,  and 
less  arbitrary  criteria,  than  those  which  we  possess  of  the 
presence  of  specific  action  could  be  discovered  ;  but,  as  yet, 
we  know  of  no  other  which  can  be  applied  universally. 
Some  kinds,  indeed,  are  so  well  marked,  and  so  peculiarly 
distinguished  from  simple  sores,  that  they  can  be  tolerably 
well  described,  and  easily  discovered  to  be  specific ;  but, 
there  are  others  which  it  is  more  difficult  to  ascertain,  owing 
to  the  difficulty  of  fixing  the  character  of  each  individual 
action. 

The  number  of  specific  inflammations  is  very  great,  and 
the  causes  which  produce  them  are  often  obscure.  In  the 
preliminary  dissertation  it  was  mentioned,  that,  whenever 
any  action  existed  strougly  in  any  one  part,  it  tended  to  in- 
duce an  inflammatory  state.  There  are,  therefore,  no  gene- 
ral, or  febrile  diseases,  which  may  not  be  attended  with  pe- 


121 

culiar  inflammations.  That  typhus  fever  is  attended  with 
local  inflammatory  action  is  pretty  certain ;  but  the  presence 
of  specific  inflammation  is  still  more  evidently  seen  in  the 
different  exanthematous  diseases.  The  diseases  called  cuta- 
neous, afford  us  also  numerous  instances  of  specific  inflam- 
mation. 

From  the  difficulty  of  discriminating  betwixt  diseases, 
which,  although  essentially  different  from  each  other,  yet 
possess  a  very  great  similarity,  we  find,  that  the  number  of 
specific  inflammations  is  confined  much  within  the  true  limits  ; 
for  we  find  many  confounded  under  the  name  of  herpetic,  &c. 
which  are  radically  different  from  each  other. 

Phagedena  has  been  used  by  medical  writers  in  a  very  ex- 
tensive sense,  and  has  been  made  to  comprehend  diseases, 
which,  strictly  speaking,  cannot  be  considered  phagedenic. 

The  phagedena  is  a  suppurating  sore,  dependent  upon  the 
application  of  a  peculiar  contagion.  No  granulations  are 
formed,  but  both  sets  of  vessels  yield  a  thin  fluid.  The  sur- 
face of  the  sope  has  a  jagged  appearance,  dependent  upon  the 
irregularity  of  the  absorption,  and  not  upon  the  deposition  of 
organic  particles,  or  granulations.  The  colour  of  the  surface 
is  dark,  but  clear,  or  fiery.  The  surrounding  integuments 
are  erysipelatous.  The  discharge  is  thin  and  serous,  and 
the  pain  considerable.  This  is  divisible  into  two  varieties  : 
First,  the  true  phagedenic,  which  does  not  go  deeper  than 
the  skin,  but  spreads  rapidly  along  the  surface.  This  kind 
frequently  stops  in  its  progress  suddenly,  arid  skins  over  as 
fast  as  it  spread.  Second,  the  noma,  or  penetrating  phage- 
dena, which  extends  deeply,  penetrating  sometimes  perpen- 
dicularly down  through  the  cellular  substance  to  the  muscu- 
lar fascia  ;  at  other  times,  proceeding  more  irregularly,  pene- 
trating deeper  at  one  part  than  another,  and  having  its  mar- 
gins ending  less  abruptly  in  the  neighbouring  skin.  This 
never  cicatrizes  rapidly ;  but,  sometimes,  when  the  sore  as- 


122 

sumes  a  healing  appearance,  it  suddenly  becomes  again  dis- 
eased, and  a  considerable  portion  sloughs  off.  The  alterna- 
tion of  proceeding  a  certain  length  in  the  cure,  and  relapsing, 
is  frequently  repeated,  and  often  renders  the  disease  very 
tedious. 

The  best  application  for  the  common  phagedena  is  an  oint- 
ment consisting  of  an  ounce  of  ung.  resinos.  and  a  drachm  of 
red  precipitate. 

The  application  of  caustic  to  the  surface  also  frequently 
stops  the  progress  of  the  disease. 

The  hepatized  ammonia,  much  diluted,  is  also  very  useful 
as  a  lotion. 

The  penetrating  phagedena  is  more  difficult  to  cure  ;  for 
even  after  the  diseased  action  is  removed,  the  ulcer  remains 
in  an  irritable,  or  overacting  state.  The  application  which 
I  have  found  most  useful  is  powdered  opium,  mixed  with  sim- 
ple ointment,  in  the  proportion  of  two  drachms  of  the  former 
to  an  ounce  of  the  latter.  After  the  phagedenic  action 
ceases,  the  sore  must  be  treated  according  to  the  genus  of  sim- 
ple ulcer  to  which  it  belongs. 

When  the  sores  seem  to  pursue  their  ravages  obstinately, 
the  most  effectual  mean  of  stopping  their  progress  (until  we 
discover  a  specific  remedy,  or  one  which  can  change  the 
nature  of  the  actiou,)  is  to  apply  the  caustic  to  every  part, 
and  so  freely,  as  to  produce  a  pretty  thick  slough.  Whenever 
this  appears  to  separate,  precipitate  must  be  applied,  in  or- 
der, if  possible,  to  prevent  the  recurrence  of  the  diseased 
action. 

When  any  considerable  vessel  is  eroded,  by  the  continu- 
ance of  this  disease,  it  must  be  tied  beyond  the  diseased 
part ;  but  we  must  be  careful  that  no  matter  from  the  sore 
gets  upon  the  wound,  otherwise  it  will  become  diseased  also. 
I  have  a  preparation,  in  which  a  part  of  the  femoral  artery 
was  opened  at  the  groin  by  this  kind  of  sore,  which  succeed- 


123 

ed  a  venereal  bubo.     No  operation,   I  understand,  was   at 
tempted,  but  compression  alone  used.     The   man  died  in  a 
short  time.     Whether  tying  the    iliac   artery,    by   cutting 
through  Poupart's  ligament,  would  have  saved  him,  is  diffi- 
cult to  say. 

The  true  phagedena  seems  always  to  confine  its  action  to 
a  particular  spot  ;*  but  many  of  these  diseases,  which  have 
been  described  under  the  same  name,  appear  to  be  capable 
of  inducing  a  general  action,  similar  to  the  venereal  disease, 
affecting  different  parts  of  the  body  in  succession.  A  case 
of  this  kind  is  related  by  Mr.  Adams,  in  his  Observations  on 
Morbid  Poisons :  A  gentleman  who  had  a  small  pustule  on 
the  prepuce,  squeezed  it  so  as  to  make  it  burst,  and  soon 
afterwards  had  connexion  with  a  woman  whom  lie  had  long 
known.  The  sore  remaining  without  healing,  he  applied  a 
solution  of  caustic,  and  had  recourse  to  mercurial  frictions. 
But,  notwithstanding  these,  the  ulcer  spread,  and  soon  reach- 
ed the  scrotum.  The  mercury  was  now  laid  aside,  and 
bark,  with  a  good  diet,  was  substituted,  after  which  the  ul- 
cer put  on  a  healing  appearance  ;  but,  before  cicatrization 
took  place,  a  feverish  fit  supervened,  with  violent  pain  in 
the  part.  In  the  course  of  a  short  time,  however,  the  un- 
favourable symptoms  disappeared,  and  a  healthy  condition 
was  again  apparently  induced.  These  paroxysms  of  fever, 
and  subsequent  amendment,  alternated  with  each  other  for 
a  considerable  time,  and  each  relapse  was  preceded  by  a 
livid  appearance  round  the  sore.  These  appearances  at  last 
went  off,  and  the  sore  assumed  more  the  aspect  of  the  true 
phagedena.  The  cicatrizing  process  now  began  at  the  upper 
part,  and  proceeded  rapidly  until  almost  the  whole  sore  was 
covered.     But,  nearly  about  this  time,  copper  coloured  spots 


*  The  neighbouring  glands  sometimes  swell  and  suppurate,  but  they  hf»al  kifld 
ly,  and  the  disease  proceeds  no  farther. 
VOL.  II.  Q 


124 

appeared  on  the  hands,  and  the  inside  of  the  right  thigh ; 
and,  in  a  day  or  two  afterwards,  an  ulcer  appeared  in  the 
throat,  with  "  bumps"  on  the  head.  Shortly  afterwards  a 
node  appeared  on  the  tibia,  and  the  patient  became  bandy. 
The  blotches  speedily  began  to  ulcerate,  and  another  ap^ 
peared  on  the  sternum.  Mercury  was  now  given  freely, 
and  at  first  with  apparent  success,  for  the  ulcers  looked  bet- 
ter, and  no  new  affection  appeared ;  but,  whenever  the  mer- 
curial action  was  beginning  to  be  fully  induced,  the  granula- 
ting appearance  of  the  surface  was  destroyed,  and  it  be- 
came of  a  dusky  colour,  discharging  "  bloody  sanies."  The 
bones  remained  stationary.  The  medicine  was  now  discon- 
tinued, and  the  patient  went  to  the  country  ;  but,  on  his  re- 
turn, in  about  a  fortnight,  "  his  throat  was  again  ulcerated.* 
Such  of  the  old  external  ulcers  as  had  not  healed,  threw  up 
a  kind  of  fungus  granulations."  The  sore  on  the  penis, 
which  never  had  been  completely  well,  had  spread  to  the 
size  of  a  shilling,  but  had  no  phagedenic,  or  specific  appear- 
ance. Mercury  was  afterwards  tried,  and  some  bones  exfo- 
liated from  the  nose.  The  ulcer  healed ;  but,  as  soon  as  he 
recovered  from  ihe  effects  of  the  mercury,  new  blotches  and 
ulcerations,  with  a  new  enlargement  of  the  tibia,  took  place. 
"  He  is  now  under  his  fifth  mercurial  course." 

In  this  case,  mercury  evidently  was  prejudicial,  except 
toward  the  end.  It  does  not  appear  that  the  caustic  had 
been  freely  applied  to  the  original  local  disease,  which  might 
have  destroyed  it.  These  affections,  which  were  by  some 
considered  as  venereal,  evidently  differed  from  that  disease, 
in  the  rapidity  of  its  progress,  in  the  appearance  of  the  pri- 
mary sore,  and  in  the  history  of  the  whole  of  the  symptoms. 
We  are  as  yet  in  the  dark  with  regard  to  a  specific  remedy 
for  these,  and  similar  affections. 

'  From  this,  it  would  appear,  that  his  throat  had  been  at  one  time  healed. 


125 

There  are  several  other  ulcers,  which  appear  upon  the 
penis  after  coition,  which  probably  depend  upon  the  applica- 
tion of  a  peculiar  contagion.  These*  are  sometimes  super- 
ficial and  phagedenic  ;  they  spread  fast,  and  heal  rapidly, 
frequently  in  the  course  of  a  night  after  precipitate  has  been 
applied.  At  other  times  they  are  deeper,  and  more  like  a 
little  cup  ;  the  surface  is  smooth  and  glossy,  without  any 
appearance  of  granulations ;  the  discharge  is  thin,  and  the 
base  and  margin  quite  soft.  The  best  remedy  is  the  caustic, 
with  the  subsequent  application,  precipitate,  or  ung.  hyd. 
nit.  dilut.  When  buboes  form,  I  have  always  found  them 
heal  without  the  use  of  mercury.  If,  however,  the  bubo  be 
the  first  symptom  which  appears,  as  is  sometimes  the  case, 
(for  the  morbid  agent  is  occasionally  absorbed  before  it  ex- 
cites action  in  the  part  to  which  it  is  applied,)  then  it  is 
generally  much  more  difficult  to  heal  than  when  it  is  pre- 
ceded by  a  local  action,  and  induced  by  the  absorption  of 
matter  generated  there. 

If  these  local,  or  primary  symptoms,  be  not  speedily  re- 
moved, a  general  disease  is  induced,  as  we  see  in  the  case 
already  mentioned,  and  as  is  proved  by  numberless  other  in- 
stances. These  general  affections  are  marked  by  ulcerations 
of  different  parts  ;  and  the  ulcers  have  a  different  appear- 
ance, according  to  the  nature  of  the  morbid  agent.  In  some 
cases  they  are  better  and  worse  at  intervals.  Mercury  has, 
in  almost  all  these  cases,  been  used ;  but,  although  some  are 
ameliorated  by  it,  yet  others  resist  its  action.  At  first,  in- 
deed, they  generally  appear  to  heal ;  for  the  mercurial  ac- 
tion, when  forming,  interrupts  the  progress  of  the  former  dis- 
eased action  ;  but,   whenever  the  mercurial  action  is  fully 


*  Many  of  these  have  been  confounded  with  the  venereal  disease,  and  treated 
accordingly. 

It  were  much  to  be  desired  that  they  should  be  accurately  described,  and  one 
land  distinguished  from  another,  for  there  .ire  probably  many  different  s;  ecies 


126 

induced,  we  sometimes  find  that  the  appearances  change, 
and  the  progress  generally  becomes  quicker  than  formerly.* 

There  is  a  disease  which  is  not  unfrequently  confounded' 
with  syphilis,  but  which  is  distinct  from  it ;  I  mean  small  ul- 
cers about  the  mouths  of  children,  which  are  more  like  aph- 
tha? than  any  thing  else  ;  but,  soon  after  their  appearance, 
small  blotches  appear  in  the  body,  which  become  first  raised 
into  a  little  flat  vesicle,  and  then  ulcerate  superficially.  These 
ulcers  have  a  watery  appearance,  not  much  unlike  tetters : 
but  the  appearance  of  the  vesication,  and  dark  colour  of  the 
preceding  blotches,  prevent  any  confusion.  Nurses  who  suckle 
these  children  have  generally  small  calyciform  ulcers  on  the 
nipples,  of  a  pale  colour,  and  discharging  a  thin  watery  mat- 
ter. I  have  had  no  opportunity  of  ascertaining  what,  constitu- 
tional symptoms  would  be  produced  by  the  continuance  of 
the  disease  in  the  nurse,  as  I  have  generally  found  that  the 
application  of  diluted  citrine  ointment  to  the  nipple  produ- 
ced a  cure,  without  any  internal  medicine.  The  constitu- 
tional symptoms  in  the  children  were  cured  by  the  same  lo- 
cal applications,  with  small  doses  of  calomel  internally. f 

I  have  likewise  observed  ulcers  on  the  lips,  throat,  and 
mouth,   which  at  first  had  a  very  doubtful  appearance ;  but 


*  Some  actions  cannot  be  induced  during  the  continuance  of  others.  Other  ac- 
tions can,  in  these  circumstances,  he  formed,  and  displace  completely  the  former 
action.  A  third  set  seem  to  give  a  modification  to  the  original  disease :  They 
change  it  to  a  certain  degree;  but  the  change  is  not  salutary,  and  they  never  dis- 
place it.  The  mercurial  action,  when  induced  during  the  existence  of  so;rre  of 
the  diseases  which  I  am  describing,  comes  under  the  last,  or  third  class.  At  first, 
during  the  formation  of  the  mercurial  action,  the  former  diseased  action  is  inter- 
rupted, in  the  same  way  as  the  natural  action  is  injured  during  the  period  of  for- 
mation of  other  actions,  when  no  peculiar  disease  previously  existed.  On  this  ac- 
count, the  sore  assumes  a  better  appearance;  and,  if  the  action  be  nearly  ter- 
minating naturally  (as  some  actionu  do,  and  as  the  primary  action  in  these  dis 
eases  more  readily  does  than  the  secondary,)  it  quickly  heals  up  ;  but,  if  this  be 
not  the  case,  the  appearances  soon  change,  ?.nd  the  disease  becomes  much  worse. 

f  There  are  some  cases,  described  by  different  authors,  of  affections  of  the  nipples 
•iud  breasts,  in  which  the  ulcers  appear  to  have  been  chiefly  of  the  phagedenic  kine: 


127 

they  evidently  are  distinct  from  syphilis,  and  belong  to  the 
suppurating  sores.  When  superficial,  thebuiT-coloured  mat- 
ter, or  inorganised  substance  which  covers  them,  has  a  fi- 
brous, or  thready  appearance,  the  margins  are  slightly  tumid, 
and  of  a  florid,  or  kind  of  pink  colour.  The  application  of 
caustic,  or  burnt  alum  is  often  sufficient  of  itself  to  cure 
these;  but  small  doses  of  mercury  sometimes  accelerate  the 
cure.  At  other  times  these  sores  penetrate  deeper,  and  af- 
fect the  bones.  The  surface,  which  is  deep,  is  covered  with 
a  thick  yellow  slough,  like  an  overacting  ulcer.  The  mar- 
gins are  tumid,  ragged,  and  of  a  light,  or  pink  colour.  Some- 
times the  disease  spreads  along  the  gum,  which  becomes  soft, 
ulcerated,  and  separates  from  the  teeth,  which  very  frequent- 
ly become  black,  and,  when  the  sockets  are  affected,  drop 
out.  I  have  not  had  an  opportunity  of  observing  these  sores 
go  the  length  of  inducing  constitutional  symptoms.  It  is  not 
easy  to  ascertain  the  cause  of  these  sores ;  sometimes  they 
succeed  the  use  of  mercury ;  but  at  other  times,  it  is  impos- 
sible to  blame  any  evident  agent.  The  transplanting  of  teeth 
sometimes  has  been  the  mean  of  inducing  sores  similar  to 
these ;  and,  in  these  cases,  the  disease  has  generally  passed 
for  syphilis.*  But  although  the  venereal  disease  may  have 
been  inoculated  in  this  manner,  it  is  certain,  from  the  appear- 
ance of  the  ulcers,  from  their  rapid  progress,  and  from  the 
sudden  effect  produced  by  a  very  smali  quantity  of  mercury, 
that  the  disease,  which  is  commonly  induced  by  transplanting 
teeth,  is  not  syphilitic. 

Sibbens  is  another  disease  which  has  been  very  frequently 
confounded  with  syphilis,  and  is  by  many  considered  to  be 
only  a  variety  of  that  disease  ;  but  they  evidently  are  differ- 
ent, as  appears  from  the  mode  of  infection,  and  the  properties 


*  Cases  of  this  kind  may  be  found  in  Mr.  Hunter's  Treatise  on  the  Venereal 
Disease,  and  in  the  third  volume  of  the  Medical  Transactions. 


128 

of  the  contagion,*  the  appearance  of  the  ulcers,  their  pro- 
gress, and  certain  circumstances  in  their  cure,  particularly 
their  requiring  less  mercury  than  venereal  ulcers  in  the  same 
state,  and  from  their  yielding  readily  to  preparations  of  mer- 
cury, which  do  not  accomplish  a  cure  of  syphilis. 

This  disease  appears  first  on  the  part  which  is  most  di- 
rectly acted  on  by  the  contagion.  This  part  becomes  red 
and  inflamed,  having  an  erysipelatous  appearance.  Ulcera- 
tion quickly  takes  place  on  a  particular  spot,  and  spreads 
rapidly  along  the  whole  inflamed  part.  The  disease  then 
advances  more  slowly  ;  the  erysipelatous  appearance  spreads 
around  the  margin  of  the  ulcer,  and  ulceration  follows  upon 
the  inflammation.  In  the  course  of  some  time  (the  precise 
period  is  not  fixed,)  the  skin  becomes  affected  with  blotches, 
or  sometimes  clusters  of  small  pustules,  the  intervening 
space  betwixt  each  being  affected  with  an  erysipelatous  in- 
flammation. These  spots  soon  ulcerate,  and  the  surface 
rises  up  into  a  fungous,  which  is  irregular,  and  has  an  aspect 
somewhat  betwixt  the  look  of  the  venereal  sore  and  a  very 
bad  scrophulous  ulcer.  The  bones  next  become  affected, 
particularly  at  the  articulating  surfaces,  which  swell,  and  be- 
come carious.  It  is  said  that  the  secondary  ulcers  in  gene- 
ral appear  first  upon  the  genitals ;  but,  of  all  those  whom  I 
have  examined,  no  affection  of  these  parts  had  taken  place, 
from  which  I  would  infer,  that  the  disease  has  no  peculiar 
tendency  to  affect  these  in  preference  to  other  parts.  It  is 
likewise  said  that  the  disease  sometimes  disappears  from  one 
part,  whilst  it  breaks  out  in  another ;  but  this  also  I  have 
never  witnessed.  The  primary  ulcers  also  have  no  tenden- 
cy, like  some  others,  to  change  their  appearance,  and  become 


*  This  disease  is  communicated  even  by  drinking  out  of  the  same  vessel  with  an 
infected  person,  even  although  that  person,  have  no  sores  on  the  lips,  but  only  in 
the  throat.  The  contagion  then  must  either  be  dissolved  in  the  saliva,  or  remain 
very  powerful,  even  when  reduced  to  a  state  of  haiku?. 


129 

milder,  or  heal  by  continuance,  but  spread,  destroying  the 
nose,  orbits  of  the  eyes,  and  face.  The  constitution  seems 
to  suffer  much  more  from  this  disease  than  from  syphilis,  in 
the  same  length  of  time  ;  for  the  patient  soon  assumes  a  pale 
sallow  look ;  and  hectic  comes  on  much  sooner  than  in  sy- 
philis. 

The  cure  of  this  disease  is  effected  by  washing  the  sores 
with  solution  of  corrosive  sublimate,  or  dressing  them  with 
precipitate  ointment,  at  the  same  time  that  we  use  mercury 
internally,  without  which  no  escharotic,  or  local  application 
whatever  will  effect  a  cure.  In  general,  less  mercury  cures 
this  disease  than  syphilis  ;  and  it  is  worthy  of  remark,  that 
permanent  cures  may  be  obtained  by  the  hyd.  mur.  corros. 
which  is  not  the  case  with  syphilis.  When  the  bones  are 
affected,  we  must,  in  conjunction  with  the  specific  remedy, 
use  such  applications  as  the  state  of  the  bone,  considered  as 
a  simple  affection,  will  require. 

The  cynanche  maligna,  and  scarlatina,  are  also  diseases 
producing  ulceration  in  the  throat.  The  sores  are  of  the 
suppurating  kind,  a  thick  lymphatic-looking,  or  inorganized 
substance  being  thrown  out,  instead  of  organic  particles,  or 
granulations.  This,  in  the  former  disease,  very  soon  be- 
comes black,  and  putrefies  ;  but  the  slough  so  formed  differs 
materially  from  that  caused  by  gangrene ;  for,  in  this  disease, 
unless  in  the  very  last  stages,  there  are  no  real  gangrenous 
sloughs.  It  is  unnecessary  here  to  make  any  particular  ob- 
servations on  these  diseases. 

Herpes*  is  a  disease  which  is  very  frequent,  and  often 
prevents  large  ulcers  from  healing,  as  these  come  to  assume 
the  action  of  herpetic  ulcers,  although,  from  their  magnitude 


*  There  are  many  different  divisions  of  herpes;  as,  for  instance,  into  the  scur- 
fy, scabby,  miliary,  &c. ;  but.  for  a  description  of  these,  I  must  refer  to  the  writers 
on  the  diseases  of  the  skin. 


130 

and  depth,  they  do  not  put  on  the  same  appearance  as  when 
the  disease  is  confined  to  the  skin.  The  large  ulcers  are  of 
a  dark  sloughy  appearance,  discharge  thin  matter,  are  pain- 
ful, and  are  surrounded  with  herpetic  ulcers,  and  scabs  in  the 
skin.  This  is  a  very  frequent  disease  on  the  legs,  and  is 
very  tedious.  Bathing  with  warm  sulphureous  water  is  of- 
ten of  service,  at  the  same  time  that  we  dress  the  parts  in 
the  intervals  with  camphorated  ointment.  Citrine  ointment 
is  also  very  useful ;  but  the  following  liquor  is  one  of  the 
best,  and  most  effectual  applications  : 

R.  Pulv.  Calcis  Vivi  Recen.  unciam. 
Flor.  Sulph.  semiunciam. 

Aq.   Font,   sesquilibram.     Coque  ad  dimidiam  dein 
cola. 

This  ought  to  be  applied  with  cloths  to  the  parts. 

When,  by  these  means,  the  disease  of  the  skin,  and  the 
specific  action  of  the  ulcer  is  removed,  pressure  is  often  of 
service  in  completing  the  cure. 

There  is  a  specific  ulcer,  which  is  met  with  most  frequent- 
ly on  the  legs,  and  which  is  very  troublesome.  The  skin 
becomes  in  several  points  inflamed,  or  of  a  dark  red  colour. 
These  parts  speedily  ulcerate,  and  the  sores  belong  to  the 
suppurating  kind,  for  no  distinct  granulations,  or  organic  par- 
ticles, are  formed ;  but  the  surface  is  smooth  and  glossy,  and 
the  discharge  thin  and  copious.  These  sores  are  generally 
pretty  deep,  in  proportion  to  their  extent,  or  of  a  cup-like 
appearance.  They  not  unfrequently  occur  in  scrophulous 
habits.  Mercury,  exhibited  in  small  doses  internally,  ap- 
pears to  be  useful.  Precipitate,  as  a  local  application,  gene- 
rally answers  very  well ;  but,  when  the  sores  become  irrita- 
ble, or  spread  under  this  treatment,  hemlock  poultices  suc- 
ceed better. 


131 

There  is  a  small  ulcer,  which  sometimes  is  met  with  on  the 
foot  of  an  irregular  shape,  fiery  appearance,  and  surrounded 
with  thick  jagged  margins,  which,  in  particular  parts,  are 
white,  and  callous.  The  neighbouring  integuments  are  of  a 
dark  red  colour.  The  discharge  is  thin,  and  the  pain  con- 
siderable. Caustic,  and  afterwards,  the  application  of  the 
adhesive  plaster,  are  the  best  local  applications.  Internally, 
the  use  of  hemlock  is  sometimes  of  service. 

It  occasionally  happens,  that,  nearly  about  the  same  time, 
most  of  the  patients  in  a  ward  of  an  hospital  shall  have  their 
ulcers  rendered  unhealthy.  They  become  foul,  dark  colour- 
ed, and  spread :  The  discharge  is  thin,  and  the  pain  is  great- 
er than  formerly.  The  application  of  cloths  dipped  in  gas- 
tric juice  is  sometimes  of  service  in  these  sores,  and  is  one 
of  the  best  remedies ;  but,  not  unfrequently,  the  patient  must 
be  removed  to  a  different  situation  before  a  cure  can  be  ob- 
tained. 

Having  made  these  detached  remarks  on  some  specific  ul- 
cers, I  shall,  in  the  succeeding  dissertations,  consider,  at 
greater  length,  others,  which  are,  in  the  general  estimation* 
considered  as  more  dangerous  and  alarming. 


vol,,  if, 


DISSERTATION  IV. 


ON    THE    SPONGOID    INFLAMMATION'. 


The  disease  which  I  am  now  going  to  consider,  has  either 
not  been  described  at  all  by  any  author,  or  lias,  when  it  was  no- 
ticed, been  considered  as  of  a  cancerous  nature.  It  is  per- 
haps one  of  the  most  alarming  diseases  to  which  we  are  sub- 
jected ;  because,  as  yet,  we  know  of  no  specific  remedy  ;  and 
an  operation  can  only  be  useful  at  a  time  when  it  is  very  dif- 
ficult to  persuade  the  patient  to  submit  to  it. 

I  have  named  it  the  spongoid  inflammation,  from  that  spon- 
gy elastic  feel  which  peculiarly  characterises  the  disease, 
and  which  continues  even  after  ulceration  takes  place. 

This  disease  begins  with  a  small  colourless  tumour,  which, 
if  there  be  no  thick  covering  over  it,  such  as  the  fascia  of  a 
muscle,  or  the  aponeurosis  of  the  foot,  is  soft  and  elastic,  but 
tense  if  otherwise.  It  is  at  first  free  from  uneasiness  ;  but, 
by  degrees,  a  sharp  acute  pain  darts  occasionally  through  it, 
more  and  more  frequently  until  the  sensation  becomes  con- 
tinued. For  a  considerable  time,  the  tumour  is  smooth  and 
even,  but  afterwards  it  projects  irregularly  in  one  or  more 
points ;  and  the  skin  at  this  place  becomes  of  a  livid  red  colour, 
and  feels  thinner.  It  here  readily  yields  to  pressure,  but  in- 
stantly bounds  up  again.  Small  openings  now  form  in  these  pro 


133 

jee iions,  through  which  is  discharged  a  thin  bloody  matter. 
Almost  immediately  after  these  tumours  burst,  a  small  fun- 
gus protrudes,  like  a  papilla,  and  this  rapidly  increases,  both 
in  breadth  and  height,  and  has  exactly  the  appearance  of  a 
carcinomatous  fungus,  and  frequently  bleeds  profusely.  The 
matter  is  thin,  and  exceedingly  foetid,  and  the  pain  becomes 
of  the  smarting  kind.  The  integuments,  for  a  little  around 
these  ulcers,  are  red,  and  tender.  After  ulceration  takes 
place,  the  neighbouring  glands  swell,  and  assume  exactly  the 
spongy  qualities  of  the  primary  tumour.  If  the  patient  still 
survive  the  disease  in  its  present  advanced  progress,  similar 
tumours  form  in  other  parts  of  the  body,  and  the  patient  dies 
hectic. 

On  examining  the  affected  parts  after  death  or  amputation, 
the  tumour  itself  is  found  to  consist  of  a  soft  substance,  some- 
what like  the  brain,  of  a  greyish  colour,  and  greasy  appear- 
ance, with  thin  membranous-looking  divisions  running  through 
it,  and  cells,  or  abscesses,  in  different  places,  containing  a 
thin  bloody  matter,  occasionally  in  very  considerable  quan- 
tity. There  does  not  seem  uniformly  to  be  an  entire  cyst 
surrounding  the  tumour,  for  it  very  frequently  dives  down 
betwixt  the  muscles,  or  down  to  the  bone,  to  which  it  often 
appears  to  adhere.  The  neighbouring  muscles  are  of  a  pale 
colour,  and  lose  their  fibrous  appearance,  becoming  more  like 
liver  than  muscle.  The  bones  are  uniformly  caries,  when  in 
the  vicinity  of  these  tumors.  If  large,  they  are  found  rough, 
and  broken  off  info  fragments ;  if  small,  they  are  generally 
soft  and  porous.  This  tumour  is  sometimes  caused  by  exter. 
nal  violence  ;  but  often  it  appears  without  any  evident  cause. 

I  know  of  no  remedy  which  has  a  power  of  checking  the 
progress  of  the  complaint,  or  removing  it.  Friction,  with 
anodyne  balsams,  sometimes  gives  relief  in  the  early  stages; 
but  it  does  not  seem  to  retard  the  progress  of  the  disease. 


134 

Extirpation  is  the  only  remedy  which  has  a  prospect  of  be- 
ing successful  ;  but  it  is  only  advisable  in  the  early  stages, 
whilst  the  disease  is  entirely  local,  and  has  not  extended  to 
the  neighbouring  glands ;  for,  after  they  become  affected, 
the  chance  of  recovery  is  greatly  diminished.  It  is,  how- 
ever, sometimes  difficult  to  persuade  patients  at  this  time  to 
submit  to  amputation,  or  extirpation,  because  the  pain  and 
inconveniences  are  inconsiderable ;  but  the  operation  ought 
to  be  urged  with  all  the  eagerness  which  a  conviction  of  its 
absolute  necessity,  and  its  precarious  issue,  if  delayed,  will 
inspire. 

After  making  these  observations,  I  shall  illustrate  the  sul> 
ject  with  the  following  cases ;  the  first  of  which  is  intended 
to  show  the  difficulty  of  extirpating  the  disease,  when  the 
operation  is  delayed  after  the  first  appearance  of  the  tumor. 
In  the  second,  we  see  the  destruction  which  the  bones  suffer 
by  it,  and  the  extent  of  parts  which  it  may  affect.  The 
third  gives  us  an  instance  of  the  affection  of  the  glands  : 
And  the  fourth,  of  the  most  advanced  stage,  or  that  in 
which  distant  parts  have  suffered.  The  last  is  an  instance 
of  the  good  effects  of  an  early  operation.  > 

CASE  I. 

William  Stirling,  without  any  very  evident  cause,  per- 
ceived a  small  tumor  on  the  top  of  the  shoulder,  about  mid- 
way betwixt  the  termination  of  the  neck  and  the  articula- 
tion of  the  humerus.  This  gradually  increased  for  some 
months,  and  by  the  time  when  I  saw  him  was  larger  than  a 
goose's  egg :  It  was  spongy  and  elastic,  and  attended  occa- 
sionally with  pain. 

Although  the  duration  of  the  tumor  was  an  unfavourable 
circumstance,  yet  I  undertook  the  operation.  I  made  an 
incision  through  the  whole  length  of  the  skin,  and  dissected 


135 

it  off  the  tumor,  (the  upper  part  of  which  was  covered  with, 
a  coat,  or  cyst,)  down  to  its  base ;  but,  when  I  now  began  to 
separate  it  from  the  parts  below,  I  found  that  it  had  no  de- 
fined bottom,  but  penetrated  down  betwixt  the  muscles, 
which  were  soft,  pale,  and  had  lost  their  fibrous  structure. 
I  therefore  cut  off  the  tumor  close  by  the  muscles,  and  then 
separating  them  with  the  back  of  the  scalpel,  I  removed  with 
the  finger  as  much  of  the  tumor  as  I  could  observe.  Seve- 
ral arteries  sprung  ;  but  these  were  pretty  readily  tied,  al- 
though the  vessels  were  very  tender.  A  troublesome  oozing, 
however,  took  place  from  many  points  of  the  diseased  mus- 
cles. This  was  moderated  by  applying  the  sponge  dipped 
in  cold  water,  after  which  the  skin  was  laid  down,  and  its 
lips  brought  close  together. 

On  dressing  the  patient  on  the  third  day  after  the  opera- 
tion, the  skin  was  found  not  to  have  united ;  but  its  lips 
were  red  and  inflamed.  In  this  state  it  continued  for  several 
days,  when  the  part  began  to  grow  tumid,  and  discharge  a 
thin  foetid  matter.  The  skin  then  retracted  still  more,  and 
a  fungus  protruded,  which  gradually  increased  ;  but  it  was 
smooth  and  regular,  and  of  a  pale  colour,  so  that  it  rather 
had  the  appearance  of  a  superficial  ulcer,  raised  up  by  a  tu- 
mor from  below,  than  the  ulcerated  surface  of  a  diseased  sub- 
stance itself.  In  this  state  it  continued  for  two  or  three 
months,  when  irregular  projections  appeared  on  the  ulcera- 
ted surface  of  the  new  tumor.  These  soon  burst,  and  a 
fungus  protruded,  of  a  carcinomatous  appearance,  and  bleed- 
ing very  frequently  and  profusely.  Swellings  of  the  axillary 
glands  succeeded  this,  and  the  patient  became  much  en- 
feebled, and  evidently  hectic.  As  I  have  not  heard  of  him 
for  several  weeks,  I  suppose  that  he  has  died. 

In  this  case  a  second  tumor  succeeded  to  the  first,  owing 
to  the  impossibility  of  extirpating  the  whole,  and  this  exact- 
ly resembled  the  original  one,  except  in  having  its  surface 


13ti 

covered  from  its  commencement  with  an  ulcer ;  but  this 
nicer  was  not  the  specific  one  of  the  spongoid  inflammation 

CASE  II. 

John  Overend  was  attacked  with  pain  in  the  right  thigh 
and  loins,  which  were  considered  as  rheumatic.  Shortly 
after  the  thigh  was  observed  to  be  elongated,  and  issues  were 
applied  over  the  hip  joint,  upon  the  supposition  of  its  being 
a  common  case  of  morbus  coxarius.  Biu  no  considerable 
relief  was  obtained  by  this ;  on  the  contrary,  the  upper  part 
of  the  thigh  swelled,  whilst  the  lower  part  wasted,  his  appe- 
tite diminished,  his  pulse  was  quickened,  and  he  passed 
sleepless  nights.  The  thigh  was  rubbed  with  anodyne  bal- 
sam, and  draughts  with  laudanum  were  given  every  night, 
but  only  with  temporary  benefit.  For  the  course  of  some 
months  these  complaints  continued,  with  occasional  remis- 
sion and  aggravation.  At  last  lie  began  to  complain  of  diffi- 
culty in  making  water ;  and  this  soon  ended  in  a  complete 
retention.  The  catheter  was  attempted  to  be  passed ;  but 
although  its  point  was  bent,  and  directed  so  as  to  correspond 
to  any  deviation  of  the  prostrate  gland  from  its  right  situa- 
tion, it  could  not  be  introduced.  By  examining  per  anum, 
a  large  elastic  tumor  could  be  felt  in  the  pelvis,  which  was 
considered  as  the  bladder.  A  trocar  was  therefore  passed 
up  the  rectum,  and  the  bladder  attempted  to  be  tapped.  A 
considerable  quantity  of  bloody  fluid  came  away  ;  but  he 
complained  of  no  pain  at  the  glans,  which  most  patients  do 
when  the  bladder  is  wounded  ;  and  a  considerable  quantity 
of  high  coloured  foetid  urine  was  voided  by  the  urethra,  and 
continued  even  afterwards  to  be  passed,  although  with  some 
difficulty.     Within  a  week  after  this  the  patient  died. 

On  dissection,  I  found  the  hip  joint  to  be  complely  sur- 
rounded with  a  soft  matter,  resembling  the  brain,  inclosed  in 


137 

thin  cells,  and  here  and  there  cells  full  of  thin  bloody  water  ; 
the  head  of  the  femoral  bone  was  quite  carious,  as  was  also 
the  acetabulum.  The  muscles  were  quite  pale,  and  almost 
like  boiled  liver,  having  lost  completely  their  fibrous  appear- 
ance, and  muscular  properties.  On  opening  the  abdominal 
cavity,  the  same  kind  of  substance  was  found  within  the 
pelvis  ;  and  the  greatest  part  of  the  inside  of  the  bones  of 
the  affected  side  were  quite  carious.  Large  cells  were 
found  in  this  diseased  substance,  containing  bloody  water ; 
and  it  was  into  one  of  these  that  the  trocar  had  entered 
when  the  bladder  was  attempted  to  be  tapped. 

CASE  III. 

James  Walker  received  a  stroke  upon  the  outside  of  the 
foot,  immediately  below  the  ankle  joint.  A  small  tumor  in- 
stantly formed,  which  continued  stationary  for  several  weeks, 
and  gave  him  little  uneasiness  ;  but  afterwards  it  began  to 
increase,  and  was  attended  with  a  shooting  pain.  The  tu- 
mor was  elastic,  pretty  tense,  and  rather  irregular  in  its  ap- 
pearance. I  was  anxious  to  operate,  but  the  man  would  not 
give  his  consent.  I  therefore  advised  frictions  with  ano- 
dyne balsam,  which  at  first  gave  him  relief,  but  soon  lost  its 
effect.  For  several  weeks  I  heard  nothing  of  him ;  but,  at 
the  end  of  this  time,  he  again  applied  to  me.  The  irregu- 
larities of  the  tumor  were  much  greater,  more  prominent,  of 
a  red  colour,  and  one  of  them  had  burst :  From  this  a  soft 
half-organized  fungus  protruded,  and  a  bloody  fluid  run  out 
constantly.  An  operation  was  again  urged,  but  the  timidity 
of  the  patient  made  him  again  refuse.  A  month  after  this 
he  came  under  the  management  of  another  surgeon.  There 
were  now  three  openings  in  the  tumor,  from  each  of  which 
protruded  a  broad  cauliflower-looking  fungus,  covered  with 
thick  fcetid  matter  ;  there  wa^  likewise  a  thin  red  serum  dis 


138 

charged  from  the  margins  of  the  ulcers.  The  tumor  was  as 
large  as  a  child's  head,  and  one  of  the  inguinal  glands  was  a 
little  swelled.  The  man  now  consented  to  lose  his  limb, 
and  amputation  was  accordingly"  performed.  Whenever  the 
turniquet  was  applied,  a  very  copious  stream  of  veinoua 
blood  issued  from  the  tumor  ;  but  this  ceased  when  the  veins 
had  emptied  themselves.  Unluckily  it  was  considered  as 
unnecessary  to  extirpate  the  diseased  gland. 

On  examining  the  leg,  all  the  bones  of  the  ankle  joint 
were  found  to  be  quite  soft  and  carious ;  the  tumour  consist- 
ed of  a  soft  substance,  resembling  the  brain,  with  light  mem- 
branous intersections.  The  cyst  on  the  upper  part  was  hard 
and  thick,  but  beneath  it  was  entirely  wanting,  having  either 
never  been  formed  betwixt  the  tumor  and  the  tendons  of 
the  muscle,  or  having  been  destroyed.  The  former  opinion 
is  the  most  probable ;  for  I  have  never  in  any  stage  found 
the  cyst  continued  over  the  under  or  back  part  of  the  tumor, 
but  it  always  terminated  imperfectly  in  the  part  on  which 
the  tumor  was  seated. 

The  wound  healed  as  well  as  could  be  desired,  but  the 
gland  became  rather  larger,  notwithstanding  which  no  opera- 
tion was  urged.  Two  months  after  this  I  was  requested  to 
visit  him.  The  gland  was  now  as  large  as  the  head  of  a 
new-born  child ;  it  was  soft  and  spongy,  and  had  at  one  part 
an  irregular  prominence,  but  the  skin  was  not  coloured. 
The  pulse  was  about  one  hundred  and  thirty,  and  the 
patient  completely  hectic.  In  this  situation  I  proposed  no- 
thing excepting  nourishment.  He  died  in  the  course  of  a 
week  after  I  saw  him,. 


139 


CASE  IV. 

The  following  case  shows  this  disease  in  its  most  advanced 
stage.  It  is  extracted  from  the  fifth  volume  of  the  London 
Medical  Journal,  and  is  intituled,  "  An  Account  of  the 
Fatal  Effects  produced  by  attempting  to  remove  a  Ganglion 
by  Seton."  It  was  drawn  up  by  Mr.  W.  Dease,  surgeon  in 
Dublin. 

"  In  July,  1781,  a  clergyman,  aged  thirty-seven,  consult- 
ed me  about  a  moveable  ganglion,  of  the  size  of  a  small  nut- 
meg, situated  between  the  fore-finger  and  thumb  of  his  right 
hand,  near  the  wrist.  He  was  eager  to  have  it  removed, 
and  had  been  advised,  for  this  purpose,  to  have  a  seton  pass- 
ed through  it,  as  the  best  and  most  certain  method ;  but,  as 
he  was  apparently  a  robust  healthy  man,  and  the  ganglion 
was  attended  with  no  pain,  I  advised  him  to  consider  it  as  a 
matter  of  no  consequence,  and  not  to  meddle  with  it.  Four 
months  after  this  I  was  desired  to  visit  him,  and  found  him 
in  a  melancholy  situation.  A  seton  had  been  passed  through 
the  ganglion,  and  the  consequences  were,  that  the  back  of 
his  hand  had  inflamed  violently,  that  the  ganglion  had  rapid- 
ly and  amazingly  increased,  and  that  the  openings  made  by 
the  seton  were  filled  with  an  ill-conditioned  fungus,  which 
sprung  up  as  fast  as  it  was  removed,  and  was  attended  with 
frequent  hemorrhage,  and  much  pain.  In  consultation,  it 
was  agreed  to  remove  this  fungus  by  a  free  incision,  which 
was  done,  and  the  metacarpal  bones  appeared  bare  and 
rough  Auother  opening  was  made  through  the  thenar,  and 
a  seton  passed  through  it,  in  order  more  effectually  to  pre- 
vent the  growth  of  fungus.  The  bark  was  administered  in 
large  quantities,  an  opiate  was  given  at  night,  and  due  atten- 
tion was  paid  to  the  regimen  of  the  patient.     This  method 

VOL.  Uk  s 


140 

seemed  to  promise  the  most  happy  event.  The  fungus  ap- 
peared to  be  entirely  destroyed,  a  laudable  suppuration  took 
place,  the  swelling  of  the  hand  subsided,  and  the  sores  in  a 
short  time  were  so  contracted  as  to  indicate  their  speedy 
cicatrization.  These  favourable  appearances,  however,  were 
not  of  long  continuance  ;  for,  after  some  time,  the  fungus  be- 
gan gradually  to  rise  again,  and  any  mode  of  keeping  it  down, 
either  by  caustic,  cutting,  or  pressure,  seemed  to  produce 
no  permanent  good  effect,  as  it  increased  rapidly,  and  at 
length  degenerated  into  the  most  frightful  cancerous  fungus 
I  have  ever  seen.  Every  local  application  that  has  been  re- 
commended in  similar  cases  was  tried  in  this,  but  without 
success  ;  and  internal  remedies  proved  equally  inefficacious. 
He  took,  for  a  considerable  length  of  time,  two  ounces  of 
bark  in  substance,  in  the  course  of  twenty-four  hours,  so 
that  he  took,  in  the  whole,  twenty-eight  pounds  of  that  me- 
dicine. The  extract  of  hemlock  had  also  a  fair  trial,  but 
produced  no  apparent  effect. 

"  When  he  had  laboured  under  this  complaint  fifteen 
months,  he  was  advised  to  undergo  the  amputation  of  his 
hand ;  but  before  he  would  consent  to  submit  to  this  opera- 
tion, he  chose  to  have  an  account  of  his  case  transmitted  to 
the  Royal  Academy  of  Surgery  at  Paris,  that  he  might 
have  their  opinion  of  it :  The  result  of  which  was,  that  the 
members  of  the  academy  pronounced  the  fungus  not  cance- 
rous, but  merely  scorbutic.  This  decision,  by  the  by, 
should  make  us  extremely  cautious  in  delivering  our  senti- 
ments on  similar  occasions,  without  seeing  the  patient,  as 
much  depends  on  the  general  appearance  of  the  sores  in 
cases  of  this  sort.  The  academy  were  of  opinion,  that  the 
disease  was  entirely  local,  and  required  only  local  treatment. 
For  this  purpose,  they  advised  that  the  fungus  should  be 
taken  down  by  means  of  euphorbium,  savine,  &c.  and  after- 
wards washed  with  salt  water.     If  this  method  proved  inek 


14! 

fectual,  recourse  was  to  be  had  to  the  actual  cautery,  from 
the  application  of  which  they  seemed  to  expect  the  most 
decisive  advantages.  To  this  mode  of  treatment  the  un- 
happy sufferer  submitted  ;  and,  during  the  space  of  six 
Weeks,  the  fungus  was  almost  every  day  burnt  down  with 
the  actual  cautery  ;  but  his  complaint  all  the  while  continu- 
ed to  gain  ground  apace  ;  so  that  being  now  disappointed  in 
all  his  expectations  of  relief  from  regular  practitioners,  he 
had  recourse  to  quacks  of  every  denomination.  The  arse- 
nic plaster  of  Plunket  was  applied,  and  he  was  salivated  for 
seven  weeks.  At  length,  after  undergoing  the  operation  of  a 
variety  of  nostrums,  he  again  placed  himself  under  my  care. 
In  consultation,  it  was  much  doubted  whether  amputation 
should  now  be  thought  of,  as  the  patient  seemed  to  be  in 
the  last  stage  of  a  cancerous  consumption.  His  limbs  were 
swelled,  and  his  whole  habit  was  wasted  by  the  repeated  he- 
morrhage from  the  fundus,  which  was  now  so  increased  in 
bulk  as  to  weigh  down  his  arm,  and  entirely  cover  the  back 
of  his  hand.  In  short,  after  every  return  of  hemorrhage,  it 
was  apprehended  that  the  next  would  put  a  period  to  his 
sufferings. 

"  The  hazard  of  the  operation,  and  the  little  chance  he 
had  of  its  proving  successful,  being  explained  to  him,  the  un- 
fortunate man  earnestly  begged  to  be  relieved  from  so  hide- 
ous a  load,  even  though  he  should  die  under  the  operation. 
I  therefore  yielded  to  his  entreaties,  and  took  off  the  hand  a 
Rttle  above  the  wrist,  in  November,  1782,  although  there 
was  a  small  indurated  gland  above  the  elbow.  On  dissecting 
the  hand  immediately  after  I  had  taken  it  off,  the  fungus,  on 
being  cut,  appeared  to  be  extremely  similar  to  the  substance 
of  the  brain,  and  to  arise  from  the  metacarpal  bones  of  the 
middle  and  fore-finger.  These  bones  were  in  part  dissolved, 
and  the  other  bones  of  the  hand  were  also  in  a  morbid 
state. 


142 

"  No  accident  occurred  during  the  amputation ;  but  soon 
after  it,  a  colliquative  diarrhoea  came  on,  which  seemed  to 
be  increased  by  opiates  and  astringents,  but  was  at  length 
checked  with  draughts  of  fixed  alkaline  salt  and  lemon  juice, 
swallowed  in  the  act  of  effervescence.     He  afterwards  took 
the  bark,  drank  seltzer  water,  and  was  allowed  a  liberal  use 
of  wine.     The  suppuration  for  some  time  was  ichorous  and 
bad,  but  he  gained  strength  daily.     At  the  end  of  seven 
weeks,  the  stump  was  completely  cicatrized,  and  the  indu- 
rated gland  above  the  elbow  had  disappeared.     He  went  into 
the  country,  drank  goat's  whey,  bathed  in  the  sea,  became 
very  corpulent,  and  seemed  to  be  in  perfect  health,  but  had 
somewhat  of  a  sallow  bloated  appearance.     He  continued 
well  till  July,  1783,  when  he  began  to  complain  of  pains  in 
his  back,  attended  with  rigidity.     These  pains,  as  they  in- 
creased, extended  down  his  thighs  and  legs,  and  occasioned 
him  to  sleep  ill  at  night.     He  grew  feverish,  his  pulse  beat 
extremely  quick,  and  his  countenance  acquired  a  shining 
yellowish  red  colour,  an  appearance  which  I  have  remarked 
to  be  characteristic  of  a  cancerous  habit.     He  now  began 
to  walk  with  difficulty.     I  took  a  small  quantity  of  blood 
from  him,  and  found  the  texture  of  the  crassamentum  ex- 
tremely loose,  and  the  serum  in  too  great  quantity.     He 
was  very  difficult  to  purge,  and  unfortunately  was  under  a 
constant  necessity  of  taking  medicines  to  procure  the  ne- 
cessary discharges.     Antimouials  in  a  variety  of  forms  were 
given,  and  the  bark  was  again  tried,  as  were  all  the  medicines 
that  are  usually  prescribed  in  rheumatic  cases.     Blisters 
were  applied,  and  issues  cut  in  his  thighs,  but  all  to  no  pur- 
pose.    He  was  obliged  to  take  to  his  bed  in  August,  and 
never  after  quitted  it. 

"  It  is  difficult  to  form  an  idea  of  the  constant  and  ex- 
cruciating pain  this  poor  man  suffered.  Opium,  though 
given  in  large  doses,  afforded  him  but  little  relief,  and  at  last 


143 

none  at  all.  He  generally  lay  on  his  back,  fixed,  as  it  were, 
to  the  bed,  the  least  motion  occasioning  the  most  intense 
pain.  As  the  disease  advanced,  he  complained  of  a  difficul- 
ty of  passing  his  urine,  which  was  loaded  with  a  viscid  mu- 
cus, and  he  once  discharged  an  oblong  calculus  ;  but  at  last 
he  voided  his  urine  involuntarily,  and  sometimes  even  his 
feces,  but  the  latter  only  rarely,  when  he  had  taken  a  pur- 
gative, which,  as  I  have  already  mentioned,  Avas  required  to 
be  of  the  most  active  kind,  otherwise  it  produced  no  ef- 
fect. 

"  During  the  whole  course  of  the  disease,  his  pulse  was 
rapid,  but  his  tongue  was  remarkably  soft  and  florid.  He 
was  never  delirious.  Latterly,  he  spit  blood  once  or  twice  ; 
his  lower  extremities  became  very  cedematous,  and  his  back 
was  covered  with  eschars ;  but  these  dropped  off,  and  the 
sores  suppurated  and  healed  kindly.  Two  months  before 
his  death,  his  pains  abated  considerably.  He  died  without 
pain,  March  4,  1784,  which  was  about  two  years  and  nine 
months  from  the  time  the  seton  was  passed,  and  a  year  and 
four  months  from  the  time  he  underwent  the  amputation. 

"  His  body  was  opened  a  few  hours  after  his  death.  The 
abdominal  viscera  appeared  to  be  perfectly  sound,  and  of 
their  natural  colour,  except  the  liver,  which  had  a  small 
steatoma  on  its  convex  surface,  but  was  in  other  respects 
healthy.  The  gall  bladder  was  rather  fuller  of  yellow  bile 
than  it  is  generally  found  to  be.  The  left  kidney  was  en- 
larged, and  on  dividing  it  longitudinally,  much  red  gravel 
was  found  in  its  pelvis,  and  the  ureter  seemed  much  lessen- 
ed. The  urinary  bladder  was  contracted,  and  its  coats  un- 
commonly thickened,  but  no  sabulous  concretions  were  ob- 
served in  it. 

"  On  each  side  of  the  vertebra?  lumborum,  the  lumbar  re- 
gions were  rendered  convex  by  a  large  cancerous  deposition, 
which  elevated  the  psose  muscles ;  and  when  the   cellular 


144 

investitures,  which  were  condensed  into  a  cyst,  were  opened, 
the  cancerous  matter  appeared  in  a  large  quantity,  in  colour 
and  consistence  exactly  resembling  the  fungus  of  the  hand, 
and  not  unlike  the  substance  of  the  brain.  The  whole 
weighed  about  five  pounds  ;  and  when  this  was  removed,  the 
last  vertebra  of  the  back,  and  the  three  first  of  the  loins, 
were  found  to  be  in  a  softened,  eroded,  and  in  some  parts  a 
totally  dissolved  state.  There  appeared  not  the  least  mark 
of  ichor,  sanies,  inflammation,  or  hardness  of  the  soft  parts  ; 
nor  were  the  mesenteric  glands  at  all  affected.  The  mat- 
ter seemed  to  have  been  really  a  cancerous  exudation,  and  to 
be  formed  chiefly  of  coagulable  lymph.  This  cancerous 
mass  seemed  to  possess  a  remarkable  dissolving  power,  which 
was  exerted  wholly  on  the  bones,  and  did  not  as  usual  in 
cases  of  this  sort,  cause  any  schirrous  hardness  of  the  sur- 
rounding soft  parts." 

CASE  V. 

A  woman,  some  time  after  receiving  a  blow  on  the  leg, 
perceived  a  small  moveable  tumour.  It  was  soft,  elastic,  and 
seated  on  the  outside  of  the  leg,  about  half  way  betwixt  the 
knee  and  ankle  joint.  I  made  a  small  incision  through  the 
skin  down  to  the  tumour,  and  dissected  it  off  to  its  base.  I 
then  dissected  the  substance  off  from  the  facia  of  the  muscle, 
and  brought  the  skin  together  with  adhesive  plaster.  It 
united  readily,  and  the  patient  was  cured.  The  tumour  was 
soft,  like  brain,  of  a  greyish  colour,  and  greasy  consistence. 


DISSERTATION  V. 


OK    THE    SCROPHULOUS    INFLAMMATION. 


Scrophula  is  a  morbid  condition,  which  has  been  called  the 
opprobrium  of  surgery,  much  more  justly  perhaps  than  any 
other  disease,  cancer  itself  not  excepted,  for  even  this  most 
dreadful  disorder  may  be  removed  by  an  early  operation ; 
but  the  nature  of  scrophula  admits  of  no  treatment  equally 
successful. 

From  the  obscurity  in  which  its  causes  are  involved,  and 
from  no  certain  method  of  cure  being  known,  I  can  only  make 
a  few  unconnected  remarks  on  this  disease. 

A  scrophulous  system  is  generally  marked  by  a  fine  skin, 
delicate  complexion,  light  blue  eyes,  with  opake  sclerotica, 
and  frequently  a  swelling  of  the  upper  lip.  At  other  times, 
especially  in  those  who  belong  to  what  has  been  called  the 
melancholic  temperament,  the  complexion  is  darker,  and  the 
skin  coarser ;  but  in  these,  at  least  when  young,  the  face  is 
generally  tumid,  and  the  look  unhealthy. 

In  these  systems,  as  will  presently  be  observed,  almost 
every  disease  is  different,  in  some  points,  from  the  same  dis- 
ease when  it  occurs  in  a  healthy  person ;  but  the  action  which 
more  decidedly  manifests  this  modification,  is  Ihe  inflammato- 
ry, insomuch,  that,  by  some,  scrophula  and  scrophulous  in- 
flammation have  been  confounded  ;  and  this  disease  has  been 
described  only  in  so  far  as  it  has  appeared  conjoined  with  in- 
flammation. We  have  therefore  almost  always  in  the  de 
scription  of  scrophula  a  ^swelling  of  the  glands,  and  subse- 
quent ulceration,  or  inflammatory  affections  of  other  parts  of 
the  body,  detailed  as  necessary  and  essential  symptoms. 


146 

The  scrophulous  inflammation  is  marked  by  a  soft  swelling 
of  the  affected  part,  which  very  frequently  is  one  of  the 
lymphatic  glands.  The  covering,  or  coat  of  the  gland,  be- 
comes slightly  thickened,  and  its  substance  more  porous  and 
doughy.*'  The  swelling  increases,  and  the  doughy  feel 
changes  by  degrees  into  that  of  elasticity,  or  fluctuation,  and 
a  firm  stool,  or  circumscribed  hardened  margin,  can  be  felt 
round  the  base  of  the  tumour.  The  skin  is  slightly  red.  If, 
at  this  time,  an  incision  or  puncture  be  made,  either  no  mat- 
ter, or  very  little,  is  evacuated,  the  lips  of  the  wound  inflame 
and  open,  displaying  a  sloughy -looking  substance  within,  and 
betwixt  this  and  the  skin  a  probe  can  often  be  introduced 
for  some  way  all  round.  If,  however,  the  disease  have  been 
farther  advanced,  then  there  is  very  little  elasticity  in  the 
tumour,  it  is  quite  soft,  rather  flaccid,  and  fluctuates  freely  ; 
the  skin  becomes  of  a  light  purple  colour,  and  small  veins 
may  be  seen  ramifying  on  its  surface.  In  some  time  after 
these  appearances  are  observed,  the  skin  may  be  felt  becom- 
ing thinner  at  one  particular  part,  and  here  it  also  generally 
becomes  of  a  darker  colour,  then  it  bursts,  and  discharges  a 
thin  fluid  like  whey,  mixed  with  a  curdy  matter,  or  thick 
white  flocculi.  The  redness  of  the  skin  still  continues,  but 
the  aperture  enlarges  in  proportion  as  the  tumour  subsides, 
forming  the  scrophulous  ulcer.  The  margins  are  smooth, 
obtuse,  and  overlap  the  ulcer ;  they  are  of  a  purple  colour, 
and  rather  hard  and  tumid.  The  surface  of  the  sore  is  of  a 
light  red  colour ;  the  granulations  are  flabby  and  indistinct  ; 
and  the  aspect  is  of  a  peculiar  kind,  which  cannot  be  de- 
scribed. The  discharge  is  thin,  slightly  ropy,  and  copious, 
with  curdy-looking  flakes.     The  pain  is  inconsiderable. 

When  this  ulcer  has  continued  for  some  time,  it  either 
begins  slowly  to  cicatrize,  or  more  frequently  the  discharge 

*  When  the  conglomerate  glands  are  affected,  the  tumour  U  generally  hard  anti 
firm  until  matter  forms. 


147 

diminishes,  and  becomes  thicker;  it  then  hardens  into  an 
elevated  scab,  of  a  dirty  white,  or  yellowish  colour.  This 
continues  for  a  considerable  time,  and  then  crumbles  oil", 
leaving  the  part  covered  with  a  smooth  purple  cicatrix. 
This  description  corresponds  to  the  mild  scrophula,  or  the 
struma  mansueta  of  the  older  writers ;  but  occasionally,  es- 
pecially if  a  bone  be  diseased  below  the  ulcer,  the  sore  has 
a  more  fiery  appearance,  the  surface  is  dark  coloured,  the 
margins  soft,  elevated,  and  inflamed,  and  sometimes  retorted. 
The  discharge  is  watery,  the  pain  very  considerable,  and 
the  surrounding  skin  inflamed.  This  has  been  called  the 
struma  maligna,  and  was  said  to  be  marked  by  the  greater 
degree  of  hardness  and  inequality  in  the  tumour,  varicose 
veins,  and  pulsatory  pain  :  It  was  likewise  said  to  be  conta- 
gious. But  although  occasionally  this  state  of  the  scrophu- 
lous  ulcer  be  preceded  by  a  hard  and  painful  tumour,  yet  it 
is  not  necessarily  so,  but  rather  seems  to  depend  upon  a  dis- 
ease of  the  parts  below,  which  generally  are  bones,  cartilages, 
or  tendons  in  a  morbid  state ;  and  hence  this  overacting 
scrophulous  sore  is  most  frequent  over  the  smaller  joints, 
particularly  the  toes. 

Sometimes  the  scrophulous  abscess,  after  bursting,  forms 
a  sinus,  the  mouth  of  which  ulcerates,  and  assumes  the  ap- 
pearance of  the  specific  ulcer;  but  the  track  of  the  sinus 
remains  in  a  suppurating  state.  This  not  unfrequently  is 
connected  with  a  diseased  bone,  or  cartilage,  or  tendon. 

Scrophulous  tumours  and  ulcers  more  readily  disappear 
during  the  winter,  and  return  again  on  the  approach  of  sum- 
mer ;  but  this  is  by  no  means  an  universal  law  of  the  dis- 
ease. 

It  is  likewise  observable,  that  swellings  of  the  glands  are 
very  apt  to  subside  pretty  rapidly  in  one  place,  and  appear 
equally  quick  in  some  other  glands,  in  the  vicinity  of  those 

vol.  fi.  T 


148 

originally  affected.  Ulcers  likewise  frequently  heal  upon 
the  appearance  of  the  disease  in  other  parts. 

When  the  joints  become  affected,  the  cartilages  swell, 
and  the  quantity  of  the  lubricating  matter  is  increased  ;  the 
tendons  are  surrounded  with  a  glairy  matter,  like  the  white 
of  egg ;  and,  lastly,  the  bone  becomes  enlarged.  These  ef- 
fects are  attended  with  stiffness  and  pain  in  the  joint,  which 
is  sometimes  intolerable,  especially  during  the  night,  and  con- 
fined to  a  single  spot,  from  the  disease  residing  chiefly  there. 
In  some  time  after  this,  small  abscesses  form  in  different 
parts  of  the  inflamed  joint,  which  gives  it  a  spongy  elastic 
feel.  These  bursting  into  one  another,  form  a  larger  cavity, 
which  communicates  with  the  articulating  surface  of  the 
bones,  and  reaches  to  the  skin,  through  which  a  fluctuation 
may  be  felt.  This  abscess  at  last  bursts,  and  discharges  a 
curdy  matter.  Long  before  this  happens,  the  bone  general- 
ly ulcerates,  and  becomes  rough.  This  disease  is  uniformly 
attended  with  hectic,  which  terminates  the  patient's  misery. 

Not  unfrequently,  in  scrophulous  people,  eruptions  appear 
on  different  parts  of  the  body,  especially  on  the  face,  which 
is  covered  with  pustules  of  a  dark  red  colour,  suppurating 
slowly,  and  sometimes  never. 

At  other  times,  we  find  incysted  tumours  on  different  parts 
of  the  body.  These  may  appear  in  any  habit ;  but  when 
they  occur  in  scrophulous  people,  they  assume  the  specific 
action  of  the  constitution ;  in  which  case,  instead  of  con- 
taining an  uniform  fluid,  like  thin  jelly,  of  a  yellowish  colour, 
as  the  simple  incysted  tumour  does,  they  are  filled  with  a 
thick  curdy  purulent-looking  matter,  or  with  serum,  con- 
taining white  flakes,  or  little  lumps,  of  a  white  substance. 

All  the  causes  capable  of  inducing  simple  inflammation 
will  of  consequence  induce  the  scrophulous  inflammation, 
provided  that  the  inflammation  be  not  induced  in  such  a 
way,  and  in  such  organs  as  make  it  heal  rapidly,  as  will  be 


149 

afterwards  noticed.  Specific  inflammation  is  likewise  modi- 
fied when  it  takes  place  in  a  scrophulous  constitution,  and  is 
much  more  tedious  in  its  cure.  This  is  evidently  seen  in 
the  small  pox  and  venereal  disease. 

Although  the  effects  of  a  scrophulous  constitution,  in  mo- 
difying action,  be  most  distinctly  observed  in  the  inflamma- 
tory action,  yet  it  does  not  operate  exclusively  on  this ;  on 
the  contrary,  we  find,  that  typhus  fever,  and  some  other  ac- 
tions, which  may  exist  without  any  perfect  local  inflamma- 
tion, are,  ceteris  paribus,  more  violent  in  scrophulous  habits 
than  in  others. 

This  constitution  is  more  easily  acted  on  by  certain  agents, 
particularly  such  as  tend  to  induce  inflammation,  than 
healthy  constitutions  in  the  same  circumstances.  It  would 
likewise  appear,  that,  on  the  contrary,  there  are  other  agents 
which  operate  with  more  difficulty.  It  is  in  general  ob- 
servable, that  scrophulous  people  are  less  easily  affected 
with  mercury.  On  a  few,  indeed,  it  operates  readily ;  but, 
when  we  attend  to  the  general  habitude  of  these  people,  we 
must  consider  the  aptitude  of  some  individuals  to  assume 
the  mercurial  action  to  depend  on  some  peculiarity  of  con- 
stitution, unconnected  with  the  scrophulous  condition. 

By  the  ancients,  and  many  of  the  moderns,  the  pituita 
was  considered  as  the  cause  of  scrophula,  producing  tume» 
faction,  by  stagnating  in  the  glands.  When  any  of  the  bile 
became  mixed  with  the  pituita,  then  the  inflammation  was 
more  violent,  and  the  ulceration  deeper.  Some  latter  wri- 
ters, convinced  that  a  simple  redundancy  of  any  particular 
humour  could  not  produce  scrophula,  had  recourse  to  the 
supposition  of  an  acrimony,  which  was  productive  of  swell- 
ing and  ulceration,  and  which  might  "  taint  the  whole  fluids 
of  the  body,"* 

*  Cullen's  First  Lines,  vol.  ir. 


150 

Others  attempted  to  explain  this  disease,  upon  the  prin- 
ciple of  debility  existing  in  the  whole  body,  but  particularly 
in  the  lymphatic  system.*  This  is  an  idea  still  more  pue- 
rile than  the  doctrine  of  morbid  humours,  which,  however 
unfounded,  had  several  plausible  arguments  to  support  it,, 
and  which  was  incontrovertible  until  the  laws  of  the  animal 
economy  were  better  understood.  Simple  debility  never 
can  give  rise  to  the  marks  of  the  scrophulous  constitution  : 
h  cannot  produce  ulcers  of  a  nature  and  appearance  so  pe- 
culiar; neither  can  it  explain  why  particular  parts  are  more 
apt  to  be  affected  than  others  ;  because,  if  debility  exist 
equally  in  every  part  of  the  absorbent  system,  then  every 
part  ought  to  be  alike  diseased;  and  if  it  exist  only  in  par- 
ticular parts,  then  it  is  necessary  to  point  out  some  cause  of 
this  partial  debility.  We  likewise  frequently  observe  very 
great  debility  in  this  system,  owing  to  general  weakness,  and 
yet  no  symptoms  of  scrophula  appear  in  consequence. 

Scrophulous  people  possess  a  peculiar  constitution,  and 
may  therefore  be  said  to  constitute,  in  one  respect,  a  distinct 
variety  of  the  human  race.  This  state  is  produced  by  a 
peculiar  condition  of  the  semen  (owing  to  the  peculiarity  of 
the  system  which  forms  it,)  or  of  the  female  organs  of  gene- 
ration, which  possess  the  same  general  nature  with  the  body, 
of  which  they  form  a  part.  When  the  organs  of  genera- 
lion  in  both  sexes  are  healthy,  that  is  to  say,  similar  in  na- 
ture to  what  may  be  considered  as  the  proper  nature  of  the 
human  race,  taken  as  a  distinct  class  of  animals,  then  the 
semen  stimulates  the  ovarium  to  the  formation  of  a  healthy 
child,  or  one  which  possesses  a  constitution,  or  susceptibili- 
ty of  performing,  and  having  actions  induced  in  it,  similar 
to  that  of  the  majority  of  mankind.  In  this  process,  the 
ovarium  is  to  be  considered  as  a  gland,  and  the  semen  as   its 

*  Bell's  Treatuc  on  Ulcer?,  p.  42?. 


peculiar  stimulus.  If,  however,  either  the  nature  of  the 
gland,  or  of  its  stimulus  be  changed,  it  is  evident  that  the 
action  induced  must  be  more  or  less  modified,  and  the  se- 
cretion or  product  changed  to  a  greater  or  less  degree  in  its 
nature  and  properties.  Were  it  possible  for  a  progeny  to 
be  produced  by  an  intercourse  betwixt  the  human  and  the 
brute  creation,  they  would  possess  a  nature  different  from 
both,  or  perform  actions  of  a  mixed  kind.  This  may  be  ob- 
served with  regard  to  mules  among  brutes.  In  the  same 
way,  a  healthy  and  scrophulous  person  must  produce  a  child 
which  differs  from  a  healthy  one,  in  having  a  certain  pecu- 
liarity of  constitution. 

Agents  produce  different  effects  in  different  animals  ;  thus 
the  matter  of  cow-pox  applied  to  the  cow  and  to  man  pro- 
duce very  different  appearances.  Agents  likewise,  in  the 
same  genus  of  animals,  produce  different  effects,  according 
to  the  peculiar  constitution  of  the  individual.  Thus,  the 
matter  of  small-pox  in  some  men  produces  only  a  slight  local 
sore,  whilst  in  the  generality  it  produces  a  general  disease, 
and  eruption.  The  same  disease  affords  an  instance  of 
changes  taking  place  in  the  constitution  after  birth,  by  the 
establishment  of  certain  actions  ;  for  it  is  rendered  unsus- 
ceptible of  the  same  action  being  induced  afterwards  ;  and, 
in  this  respect,  is  brought  to  resemble  the  constitution  of  a 
different  genus  of  animals,  with  regard  to  that  disease-. 
There  are  some  constitutions,  such  as  those  called  irritable, 
in  which  certain  symptoms  of  febrile,  and  other  actions,  are 
much  more  violent  than  in  people  of  a  different  description. 
In  them,  for  instance,  typhus  fever  is  attended  with  a  very 
frequent  pulse,  and  yet  the  other  effects  of  this  action  are 
not  violent  in  the  same  proportion. 

Peculiarity  of  constitution  is  often  manifested  by  no  evi- 
dent sign,  and  the  modifications  of  actions  induced  are  often 
marked  by  no  perceptible  diseased  phenomena,  which  mar 


152 

be  considered  as  belonging  exclusively  to  that  constitution. 
But,  in  the  scrophulous  constitution,  there  are,  in  almost 
every  instance,  perceptible  modifications  of  the  formative 
action,*  producing  a  peculiar  appearance  of  the  eye,  coun- 
tenance, &c.  as  has  already  been  mentioned ;  and  although 
some  diseased  actions,  which  receive  modifications  from  this 
peculiarity  of  constitution,  may  not  be  attended  with  obvi- 
ous alterations,  yet  others,  especially  such  as  are  attended 
with  an  inflammatory  condition,  are  distinctly  changed.  It 
is  these  changes  which  constitute  what  in  common  language 
has  been  called  scrophula,  which  is  merely  a  peculiarity  of 
a  common  action,  (namely,  inflammation,)  which  is  depend- 
ent, not  upon  any  particular  nature  of  the  agent  or  exciting 
cause,  but  upon  the  peculiarity  of  constitution,  which  is 
susceptible,  by  these  agents,  of  such  an  action. 

From  what  has  been  said  it  will  appear,  that  I  consider 
Uie  scrophulous  inflammation,  or  what  has  in  common  lan- 
guage been  called  scrophula,  merely  as  an  accidental  circum- 
stance, occurring  in  a  scrophulous  constitution ;  but  it  is  by 
much  the  most  dangerous  and  troublesome  effect  of  the  pe- 
culiarity of  constitution.  It  has  likewise  a  very  evident  ef- 
fect in  increasing  this  condition  of  the  system ;  for  we  find, 
that  the  probability  of  scrophula  appearing  in  a  child  is,  ce- 
teris paribus,  correspondent  to  the  presence  or  absence  of 
scrophulous  inflammation  in  the  parent ;  or,  in  other  words, 


*  The  morbid  condition  of  the  formative  action  is  very  frequently  manifested 
in  the  bones,  which  are  less  perfect,  that  is  to  say,  softer,  containing  less  calcare- 
ous earth,  and  later  of  being  formed.'  Thus,  the  teeth  are  longer  of  appearing  ; 
the  bones  of  the  head  are  soft  and  yielding,  and  hence  the  head  is  large ;  the  long 
bones  bend  and  lose  their  shape,  or  their  extremities  swell,  and,  from  being  more 
vascular  than  their  nature  is  fitted  for,  inflammation  is  very  apt  to  be  induced. 
The  yielding  and  increasing  of  the  bones  of  the  cranium  is  likewise  attended  with 
a  similar  effect,  for  the  brain  becomes  too  large  in  proportion  to  the  rest  of  the 
body,  and  is  very  apt  to  inflame,  and  have  effusions  formed  into  it.  At  other 
times,  the  diseased  state  of  the  formative  action  appears  most  distinctly  at  the 
surface,  the  skin  being  rough,  and  very  apt  to  df  sqaamate. 


153 

that  those  who  have  either  at  the  time  of  marriage,  or  before 
it,  had  scrophulous  inflammation,  are  more  likely  to  have 
their  children  strongly  scrophulous,  than  others  of  the  same 
family,  who  have  not  had  inflammation.  It  is  likewise  cer- 
tain, that  if,  by  any  cure,  we  can,  for  one  or  two  generations, 
prevent  the  appearance  of  scrophulous  inflammation,  the 
children  will  become  less  and  less  diseased,  or  have  less  pe- 
culiarity of  constitution  ;  but  if,  by  any  accident,  scrophu- 
lous inflammation  be  in  one  of  the  descendants  excited,  even 
in  a  slight  degree,  his  immediate  progeny  will  be  more  dis- 
eased than  he  himself  before  the  induction  of  the  inflamma- 
tion.* 

"With  regard  to  the  exciting  causes  of  scrophulous  inflam- 
mation, I  may  remark,  that  they  are  similar  in  kind  to  those 
capable  of  inducing  simple  inflammation  ;  but  they  frequent- 
ly operate  more  powerfully ;  that  is  to  say,  causes  which 
would  scarcely  induce  inflammation  in  a  healthy  person, 
may  induce  a  local  disease,  and  inflammation,  in  a  scrophu- 
lous habit ;  because  the  different  parts  of  the  body  perform 
their  functions  less  healthily  in  a  strongly  scrophulous  per- 
son, and  are  more  easily  deranged.  In  every  system,  those 
parts  which  are  most  delicate,  or  require  the  greatest  per- 
fection of  action  in  order  to  keep  them  right,  are  most  easily 
deranged.  Now,  in  scrophulous  people,  the  natural  action 
being  modified,  the  body  becomes  more  delicate,  and  is  more 
susceptible  of  derangement,  especially  those  parts  which  na- 
turally are  delicate,f  or  require  a  perfection  of  action.  The 
glands  seem  to  be  among  the  most  delicate  organs ;  for  they 
have  not  only  to  perform  the  formative,  or  nutritive  func- 


*  Some  gentlemen  have  denied  that  scrophula  was  a  hereditary  disease ;  but  it 
is  unnecessary  to  offer  any  argument  on  this  subject. 

f  This  term  is  used  here  in  a  different  sense  from  its  common  one,  which  signi- 
fies sensibility,  or  delicacy  with  regard  to  sensation,  and  capability  of  being  act- 
ed on. 


154 

tion,  in  common  with  every  other  part,  but  they  have  also 
to  perform  a  separate  and  distinct  function,  or  change  the 
nature  of  certain  fluids  which  are  brought  to  them.  It  is  on 
account  of  the  natural  delicacy  of  ihe  glandular  system  be- 
ing increased  by  the  diseased  condition  of  the  general  sys- 
tem, and  of  the  exposure  of  the  lymphatic  glands  to  the  ac- 
tion of  stimulating  maiter,  taken  up  by  the  absorbents  on 
the  surface,  as,  for  instance,  matter  from  scabs  on  the  head 
of  children,  that  this  species  of  inflammation  most  common- 
ly appears  in  the  lymphatic  system  ;  but  this  system  does 
not  seem  to  be  the  peculiar  seat  of  the  diseased  condition, 
as  some  suppose,  nor  to  be  otherwise  predisposed  to  scro- 
phulous  inflammation,  except  in  so  far  as  its  natural  delicacy 
is  increased  by  the  diseased  condition  which  it  possessed,  ab 
initio,  in  common  with  the  rest  of  the  body ;  and  consequent- 
ly, it  is  rendered  less  able  to  perform  its  functions  properly, 
the  effect  of  which  is,  the  induction  of  a  new  local  diseased 
action,  or  slow  inflammatory  action,  by  the  slightest  cause. 

Besides  the  common  exciting  causes  of  inflammation,  the 
particular  formation  of  organs  may  induce  this  disease,  or  at 
least  make  very  slight  causes  produce  it.  Thus,  for  in- 
stance, in  people  with  a  very  small  narrow  chest,  the  circu- 
lation of  the  blood  must  be  performed  with  greater  action 
than  in  other  circumstances,  and  thus  may  tend  to  induce 
an  inflammatory  state.  When  the  bones  are  very  vascular, 
and  imperfectly  formed,  they  are  apt  to  have  a  morbid  de- 
gree of  action  excited  in  them  by  very  slight  causes  ;  and 
the  same  holds  true  with  regard  to  any  other  part  of  the 
body  which  is  imperfectly  formed,  or  which  is  not  exactly 
fitted  for  the  support  and  performance  of  its  requisite  ac- 
tion.* 


*  Parts  which  are  improperly  organized,  or  which  are  not  in  every  respect  simi- 
lar, both  in  their  structure  and  constitution  (by  which  I  mean,  mode  of  acting  in 


155 

Scrophulous  inflammation  is  in  general  dangerous  and  te- 
dious, in  a  degree  proportioned  to  the  effects  and  duration  of 
simple  inflammation  upon  the  same  parts.     Thus,  simple  in- 
flammation of  one  of  the  conglobate  glands  of  the  neck,  is 
tedious,  but  not  dangerous ;  and  the  same  holds  true  of  scro- 
phulous inflammation ;  but  the  duration  of  this  is  much  long- 
er.    Simple  inflammation  of  the  lungs,  again,  is  dangerous; 
and  scrophulous  inflammation  is  infinitely  more  so.     Such 
parts  as  heal  easiest,  when  affected  with  simple  inflammation, 
or  ulceration,    recover  soonest  from  scrophulous  inflamma- 
tion ;  and  the  same  causes  which  retard  the  one  will  retard 
the  other  also.     Thus,  the  same  cause  which  renders  a  su- 
perficial simple  ulcer  unhealthy  and  chronic,  will  prevent  a 
superficial  scrophulous  ulcer  from  healing:  But,  if  none  of 
these  causes  operate,  then  scrophulous  inflammation,  or  ul- 
ceration, will  heal  pretty  readily,  provided  that  simple  in- 
flammation, or  ulceration  of  the  same  parts,  would  do  so ;  but, 
for  this  purpose,  it  must  be  quickly  induced ;  for  all  inflam- 
mation, or  ulceration,  which  is  slowly  induced,  is  slowly  re- 
moved.    As  a  confirmation  of  these  positions,  we  find,  that 
a  blister  on  a  scrophulous  person  will  heal  readily,  because 
the  inflammation  is  induced  acutely,  or  with  a  certain  degree 
of  quickness,  and  has,  when  the  affection  is  simple,  a  prompti- 
tude to  heal,  which  manifests  itself  also  in  scrophulous  peo- 
ple.    In  this  instance,  the  difference  in  the  time  required  to 
heal  the  inflammation  in  a  sound  and  a  scrophulous  person  is 
not  perceptible  ;  because  the  affection,  if  simple,  has  a  ten- 
dency to  heal  immediately.     But,  in  a  deep  wound,  espe- 


general,)  to  what  naturally  they  ought  to  be,  are  not  only  less  capable  of  perform- 
ing their  actions  aright,  but  likewise  are  to  be  considered  as  in  some  respect  ex- 
traneous to  the  human  body,  or,  as  it  were,  insulated,  and  do  not  correspond  ex- 
actly to  other  parts.  They  therefore  receive  less  support  from  the  neighbour 
ing  parts,  and,  consequently,  have  their  power  diminished.  The  imperfection  ol 
action  consequent  to  these  causes  is  proportioned  to  £h*  morbid  condition  of  tire 
part. 

VOL.  II.  V 


J-JG 

dally  ii  contused,  we  find  the  difference  more  marked;  be- 
cause here,  although  the  constitution  be  healthy,  the  dura- 
tion of  the  disease  is  considerable;  and,  in  a  scrophulous 
person,  the  cure  is  protracted  still  longer,  and  the  sore  as- 
sumes a  specific  appearance.  In  diseases  of  the  glands,  the 
difference  is  still  more  perceptible  :  because  the  disease,  al- 
though simple,  is  longer  in  duration.  In  affections  of  the 
bones  and  cartilages,  the  same  is  observed.  When  a  bone 
is  fractured  in  a  healthy  person,  it  unites  without  inflaming  ; 
and,  in  a  scrophulous  person,  unless  the  diathesis  be  exceed- 
ingly strong,  it  likewise  does  so,  but  the  union  is  longer  of 
taking  place ;  but,  if  a  bone  inflames  in  a  sound  person,  the 
disease  is  very  tedious ;  and,  in  a  scrophulous  habit,  it  is  in- 
finitely more  so.  The  same  holds  true  with  regard  to  ten- 
dons and  cartilages  ;  and  hence  the  greater  danger  of  a  sprain 
m  a  scrophulous  than  a  healthy  person.  From  these,  and 
other  facts,  which  it  is  altogether  unnecessary  to  mention,  it 
fully  appears,  that  scrophulous  inflammation  is  tedious  and 
dangerous,  in  proportion  to  the  progress  and  effects  of  sim- 
ple inflammation  and  its  consequences,  when  it  attacks  the 
same  parts  ;  but  this  proportion  is  not  regular  and  uniform ; 
but  the  duration  increases,  in  a  higher  ratio,  in  proportion  as 
the  simple  inflammation  and  ulceration  of  the  same  parts, 
and  in  the  same  circumstances,  is  tedious.  Thus,  a  deep 
wound  in  a  healthy  person  is  pretty  long  of  healing  ;  but,  in 
a  scrophulous  person,  it  is  much  more  so.  Simple  inflam- 
mation of  a  gland  is  still  more  tedious  than  the  same  extent 
of  inflammation  in  cellular  substance ;  and  scrophulous  in- 
flammation is  still  longer  of  running  its  progress  ;  but  the 
proportion  betwixt  the  duration  of  the  scrophulous  inflam- 
mation, in  these  two  cases,  is  not  exactly  as  the  duration  of 
the  simple  inflammation  of  the  two,  compared  with  each 
other,  but  is  in  an  increased  ratio. 


157 

When  scrophulous  inflammation  is  excited  in  the  vicinity 
of  a  part  already  possessing  this  action,  it  occasionally  re- 
moves the  action  from  that  part,  in  the  same  way  as  inducing 
simple  inflammation  by  a  blister  in  one  part  cures  the  same 
disease  in  another  part  in  the  vicinity.  It  was  an  observa- 
tion of  this  fact  which  made  it  be  considered  as  part  of 
the  description  of  scrophulous  tumours  and  ulcers,  that  they 
not  unfrequently  disappear  in  one  place,  whilst  they  show 
themselves  in  another  ;  but,  in  every  instance,  this  disap- 
pearance is  an  effect,  and  not  a  cause ;  for  we  uniformly  ob- 
serve, that,  before  it  takes  place,  the  new  part  has  begun  to 
inflame  or  swell. 

With  regard  to  the  diagnosis  of  scrophula,  it  is  impossible 
to  say  any  thing  satisfactory;  because,  as  long  as  the  in- 
flammation remains  trifling,  ami  the  skin  sound,  it  is  very 
difficult,  if  not  impossible,  to  distinguish  a  scrophulous  swell- 
ing from  any  other  of  a  different  kind.  Much  assistance  has 
been  supposed  to  be  derived  from  the  situation  of  the  tumours, 
most  of  those  which  appear  in  the  neck  being  considered  as 
scrophulous  ;  but  this  is  certainly  a  false  principle.  From 
the  same  method  of  reasoning,  most  swellings  in  the  groin 
have  been  considered  as  venereal,  whilst  many  are  of  a  very 
different  nature,  and  not  a  few  scrophulous.  The  best  plan 
is  to  attend  to  the  appearance  of  the  body  in  general,  and  to 
the  presence  or  absence  of  the  sign  of  a  scrophulous  system  ; 
next,  whether  any  ulceration  be  present,  by  the  absorption 
of  matter,  from  which  these  swellings  may  have  been  pro- 
duced. If  these  be  present  in  a  system  not  possessing  the 
marks  of  scrophula,  the  probability  of  the  tumour  being 
scrophulous  is  less  ;  but,  if  the  system  be  evidently  scrophu- 
lous, then  we  must  consider,  whether  the  glands,  originally 
swelled  by  the  absorption  of  matter,  have  assumed  the  slow 
inflammation  of  a  scrophulous  nature,  or  have  assumed  a  dif- 
ferent species  of  inflammation,   dependent  upon  the  peculi- 


158 

aiity  of  the  matter  ;  for  they  can  scarcely  be  supposed  to  be 
simply  inflamed.  Scrophulous  swellings  of  the  lymphatic 
glands  are  generally  soft  and  doughy,  and  frequently  give 
the  feel  of  containing  a  fluid  long  before  suppuration  has 
taken  place.  They  are  at  first  free  from  pain,  and,  in  mild 
cases,  even  toward  the  end,  the  pain  is  inconsiderable. 
When  matter  is  formed,  the  skin  generally  becomes  purple^ 
and  then  gives  way  in  a  small  spot.  Swellings  of  the  secre- 
ting glands  are  to  be  distinguished  from  schiro-cancer,  by 
the  hardness  being  less,  the  pain  very  inconsiderable,  the 
presence  of  a  scrophulous  habit,  and  by  the  feel  of  fluctua- 
tion much  earlier  than  takes  place  in  cancer.  Upon  the 
whole,  the  presumption  of  any  affection  being  scrophulous, 
is  to  be  formed  by  the  presence  of  the  marks  of  a  scrophu- 
lous diathesis,  and  the  absence  of  such  symptoms  and  ap- 
pearances, whether  antecedent  or  present,  which  character- 
ise inflammation  of  a  different  species,  or  make  us  suppose 
it  to  have  taken  place,  whether  this  be  simple  or  specific. 
Scrophulous  ulceration  is  distinguished  by  its  peculiar  as- 
pect, joined  with  the  marks  of  a  scrophulous  habit. 

Of  the  Treatment  of  the  Scrophulous  Inflammation. 

If  the  foregoing  reasoning  be  just,  it  will  appear,  that,  in 
scrophulous  habits,  our  great  attention  ought  to  be  directed 
to  the  prevention  of  the  scrophulous  inflammation,  which 
is  to  be  done  by  avoiding,  as  far  as  lies  in  our  power,  the 
operation  of  any  agent  tending  to  excite  inflammation.  It 
has  been  observed,  that  in  scrophulous  systems,  very  slight 
causes  were  sufficient  to  produce  disease ;  because  the  parts 
on  which  they  act,  possess  a  peculiar  constitution,  and  are 
less  capable  of  performing  their  natural  and  healthy  func- 
tions properly,  and  therefore  are  sooner  rendered  diseased. 


159 

Inflammation  may  also  be  induced  by  the  structure  of  the 
part  being  such  as  to  prevent  it  from  carrying  on  its  func- 
tions properly,  and  therefore  the  same  effect  is  produced 
as  in  the  former  case,  where  the  constitution,  or  mode  of  ac- 
tion, and  not  the  evident  structure  or  mechanism  of  the  part, 
was  affected. 

The  lungs  are  to  be  prevented  from  assuming  the  scrophu- 
lous  inflammation,  by  avoiding,  in  the  first  place,  all  the  com- 
mon exciting  causes  of  pneumonia,  such  as  cold,  damp,  &c. 
It  is,  in  the  next  place,  to  be  prevented,  by  avoiding  such 
causes  as  tend  to  increase  the  circulation  in  the  chest,  or  af- 
fect the  function  of  respiration.  Hence,  violent  exercise, 
climbing  ascents,  intoxication,  thick  hazy  atmosphere,  are  to 
be  guarded  against. 

The  lymphatic  glands  are  to  be  prevented  from  inflaming, 
by  avoiding  exposure  to  cold,  and  to  the  other  common  causes 
of  inflammation,  but  especially  by  preventing  the  absorption 
of  irritating  matter,  such  as  matter  from  sores,  and  the  like. 
A  neglect  of  this  is  perhaps  one  of  the  most  frequent  causes 
of  scrophulous  inflammation,  for  swellings  of  the  glands  of  the 
neck  can  very  often  be  distinctly  traced  to  scald  head,  to  ul- 
cerations about  the  ears,  little  sores  in  the  mouth,  caries  of 
the  teeth,  or  to  the  absorption  of  particles  of  food  allowed  to 
remain  and  undergo  fermentation  in  the  mouth.  The  greatest 
attention  ought  therefore  to  be  paid  to  cleanliness.  The 
head  ought  in  scrophulous  children,  to  be  washed  daily,  and 
the  sweat  removed  from  behind  the  ears  ;  vermin  ought  to  be 
diligently  removed :  but  mercurial  and  acrid  preparations, 
frequently  used  with  that  intention,  ought  to  be  avoided. 

The  mesenteric  glands  are  to  be  prevented  from  inflaming, 
by  supporting  the  action  of  the  bowels,  and  preventing  the 
formation  of  irritating  matter,  which,  when  absorbed,  may 
swell  these  glands.  Nourishing  digestible  diet,  conjoined 
with  rhubarb,  and  such  remedies  as  act  as  tonics,  at  the  same 


time  that  they  keep  the  belly  easy,  are  of  use  in  this  view ; 
for  the  whole  process  of  digestion  is  thus  supported,  and  nei- 
ther the  feculent  part  of  the  food,  nor  the  mucus  of  the  intes- 
tines, become  morbidly  irritating. 

The  other  parts  of  the  body  are  to  be  prevented  from  in- 
flaming, by  avoiding  the  usual  causes  of  inflammation,  and  the 
action  of  whatever  may  injure  the  healthy  condition  of  the 
part,  or  impede  the  natural  action.  Thus,  the  knee  and 
ankle  joint,  occasionally  become  affected  with  scrophulous  in- 
flammation after  fatigue,  which  injures  the  healthy  condition 
of  the  parts. 

Besides  these  precautions,  which  are  necessary  in  those  of 
an  evidently  scrophulous  constitution,  with  regard  to  particu- 
lar parts,  it  is  likewise  useful  to  preserve  as  vigorous  and  per- 
fect a  performance  of  the  natural  actions  of  the  system,  con- 
sidered in  the  aggregate,  as  possible,  by  which  we  lessen  the 
risk  of  anyone  part  becoming  diseased;  for,  whatever  impedes 
or  diminishes  the  performance  of  the  natural  and  healthy  ac- 
tion of  a  part  (and  in  this  case,  the  whole  body  is  to  be  consi- 
dered as  made  up  of  parts,)  renders  that  part  more  susceptible 
of  disease,  or  derangement  of  its  actions.  Cleanliness,  pure  air, 
warm  and  sufficient  clothing,  nourishing  and  digestible  diet, 
invigorating  exercise,  and  a  due  proportion  of  sleep,  are  there- 
fore very  powerful  preventives  of  this  species  of  inflamma- 
tion, insomuch,  that  Dionis  remarks,  that  seventy-five  out  of 
the  hundred,  who  came  to  be  touched  by  the  king,  were  chil- 
dren of  the  poor  peasants. 

When  scrophulous  inflammation  does  take  place,  then  this 
invigorating  plan  is  had  recourse  to  as  a  cure,  whilst,  in 
truth  it  is  most  useful  as  a  prophylactic.  The  invigorating 
plan,  which  consists  in  the  use  of  good  diet,  moderate  exer- 
cise, sea  bathing,  Sec.  is  indeed  useful  at  this  period,  both 
because  it  tends  to  make  the  disease  more  easily  overcome, 
and  prevents  other  parts  from  being  injured ;   but  its  utility 


161 

.is  still  greater  as  a  prophylactic  ;  and  it  does  not  appear  to 
have  any  certain  efficacy  in  promoting  the  resolution  of  scro- 
phulous  tumours,  because  these  have  naturally  a  strong  dis- 
position to  advance  slowly  to  suppuration,  and  therefore  are 
not  readily  affected  by  such  means  as  tend  simply  to 
strengthen  the  system,  or  support  its  actions,  because  these 
do  not  change  its  peculiarity,  or  morbid  modification,  which 
existed,  ab.  origine.  But,  when  the  tumours  have  proceed- 
ed the  length  of  ulceration,  then  they  have  gone  a  step  far- 
ther to  a  natural  termination ;  and,  although  the  means  which 
strengthen  the  system  cannot  remove  the  scrophulous  dia- 
thesis of  the  system,  they  may  nevertheless  accelerate  the 
cure  of  a  chronic  tedious  ulcer,  which  is  slowly  tending  of  it- 
self to  a  termination. 

The  remedies  called  agentes  similes  operate  more  direct- 
ly on  the  scrophulous  mode  of  action  than  those  means 
which  tend  simply  to  strengthen  the  system,  and  may  be 
usefully  conjoined  with  them,  because  these  agents  tend  to 
induce  an  action  different  from  the  scrophulous  one,  at  the 
same  time  that  it  possesses  a  certain  coincidence  with, 
or  general  resemblance  to,  the  natural  or  healthy  action, 
Hence,  the  bark  has  been  frequently  found  to  be  useful  in 
the  cure  of  scrophulous  inflammation,  but  oftener  of  ulcera- 
tion than  tumefaction  of  the  glands,  for  the  reason  mention- 
ed above.  It  does  not  appear,  however,  to  possess,  by  any 
means,  that  certain  power  of  curing  scrophulous  affections 
which  is  attributed  to  it  by  Dr.  Fothergill,  and  several  other 
authors ;  nor  are  we  to  suppose  that  it  shall  infallibly  cure 
scrophulous  inflammation,  or  ulceration  of  parts,  which,  even 
when  affected  with  simple  inflammation,  are  very  difficult  to 
be  cured.  If  we  find  it  difficult  to  cure  a  simple  inflamma 
tion,  or  ulceration  of  a  tendon,  cartilage,  or  bone,  we  must 
not  be  disappointed  if  even  a  specific  remedy  for  scrophula 
C^rantin^  s.nch  a  one  ever  to  be  discovered)  were  to  prove 


162 

ineffectual  in  procuring  a  speedy  restoration  to  health. 
The  bark  is  likewise  often  ineffectual,  because  it  is  impro- 
perly administered.  Given  in  small  quantities,  once  or 
twice  a-day,  as  is  frequently  done,  it  may  prove  a  stomachic, 
and  increase,  like  other  tonic  bitters,  the  power  of  the  sto- 
mach, or  the  functions  dependent  on  it  ;  but  we  never  can 
thus  obtain  the  benefits  of  the  specific  action  of  the  bark  on 
the  system.  For  this  purpose,  it  must  be  given  liberally, 
in  as  great  doses,  and  as  frequently  repeated  as  can  be  done 
without  producing  continued  sickness,  or  vomiting ;  and  this 
must  be  continued  regularly,  late  and  early,  not  for  days, 
but  perhaps  for  weeks,  at  the  same  time  that  wre  prevent  the 
action  of  such  causes  as  wrould  counteract  the  effects  of  the 
bark,  such  as  poor  diet,  bad  air,  confinement,*  &c.  Ad- 
ministered in  this  way,  the  bark  may  be  rendered  really  use- 
ful, not  only  in  the  cure  of  scrophulous  ulceration,  but  per- 
haps of  many  other  diseases,  whilst,  in  the  common  way  of 
prescribing  it,  little  or  no  benefit  is  derived  from  it. 

The  muriated  barytes  has  been  recommended  by  Dr. 
Crawford,f  and  has  of  late  been  tried  in  France  by  M. 
Pinel^:  and  others.  It  does  not  appear  to  have  any  influence 
on  tumid  glands,  or  scrophulous  tumours  ;  but  occasionally 
it  is  serviceable  in  scrophulous  ulceration.  It  is,  howTever, 
a  medicine  on  which  very  little  dependence  can  be  placed, 
and  which  fails  in  a  great  majority  of  instances. || 

*  See  what  has  been  said  on  this  subject  when  treating  of  the  cure  of  morti- 
fication. 
f  See  the  second  volume  of  Medical  Communications. 
X  Nomographic  Philosophique,  vol.  ii.  p.  238. 
jj  When  it  is  wished  to  prescribe  it,  the  following  is  a  very  good  formula  : 

R.  Terra>  Ponder.  Salit.  Chryst  gr.  x. 
Aq.  Font. 

Aq.  Cassia  utriusque  uncias  iii. 
Syrupi  Auient.  uncias  ii. 

Half  an  ounce  of  this  may  be  given  at  first,  twice  or  three  times  a-day,  and  gra- 
dually increased  to  such  quantity  as  the  stomach  can  bear  without  sickness. 


163 

The  muriate  of  lime  has  been  proposed  by  M.  de  Four 
croy;  it  is  given  more  liberally  than  the  miniated  barytes, 
but  it  is  not  more  efficacious. 

Iron  by  itself,  or  mixed  with  the  fixed  or  volatile  alkalis, 
has  also  been  frequently  employed,  but  with  very  little 
benefit.* 

Burnt  sponge,  millipedes,  vitriolated  tartar,  and  many 
other  trifling  remedies,  which  were  at  one  time  in  repute,  are 
now  deservedly  neglected. 

Cicuta  has  been  greatly  recommended  by  Dr.  Fothergill 
and  others.f  It  has  very  little  effect  on  scrophulous  tu- 
mours, or  mild  ulcers  ;  but,  when  administered  freely,  it  is 
sometimes  of  service  in  the  irritable  fiery  ulcer,  which  was 
by  the  older  writers  called  struma  maligna. 

Mercurv  is  another  remedy,  which  at  one  time  was  much 
employed  in  this  disease  ;  but  few  expect  any  benefit  from  it 
now.  Gentle,  or  what  has  been  called  alterative  courses, 
are,  however,  still  recommended  by  many,  with  a  view  to 
satisfy  the  patient.  Various  preparations  have  been  used. 
Some  exhibited  the  corrosive  sublimate,  others  the  calomel, 
whilst  the  acetite  of  mercury,  mixed  with  the  powder  of 
vipers  and  earth-worm,  with  the  rust  of  iron,  was  much  em- 
ployed on  the  continent. %  Antimony  has  frequently  been 
conjoined  with  this,  but  without  much  benefit. 

Nitrous  acid  has,  I  believe,  in  some  cases,  a  considerable 
power  over  scrophulous  ulcers.  From  the  trials  which  I 
have  made  with  it,  I  am  inclined  to  attribute  some  effect  to 
it  in  promoting  the  suppuration  of  scrophulous  glands,  or 


*  This  metal  was  one  of  the  principal  ingredients  in  a  remedy  used  by  the 
Marechal  de  Rougeres,  which  consisted  of  filings  of  iron,  sal  ammoniac,  salt  of 
tartar,  6:c.    Journal  deMed.  toiu.  kI.  p.  219. 

f  This  is  highly  recommended  by  M.  Martcau.     Journ.  de  Med.   torn,   iv 
;..  121. 

t  Pratique  Moderne  dc  Chirurgcr,  par  Ravaton,  torn.  H.  p.  33. 

VOL.  II.  X 


/ 

164 

f 

tumours,  and  in  disposing  ulcers  to  heal.  Two  or  three 
drachms  may  be  given  daily,  and  continued  for  a  fortnight, 
provided  no  bad  effect  be  produced  by  it,  such  as  pulmonic 
affections,  &c.  If,  within  this  time,  no  melioration  appear, 
we  may  give  up  this  medicine. 

The  hepatised  ammonia,  in  the  dose  of  eight  or  ten  drops, 
three  times  a-day,  is  sometimes  useful  in  abating  the  pain, 
and  changing  the  fiery  appearance  of  the  irritable  ulcer,  or 
struma  maligna. 

The  breathing  of  oxygene  has  been  proposed  as  a  cure 
for  this  species  of  inflammation  ;  but  it  will  be  extremely 
difficult  for  the  advocates  of  pneumatic  medicine  to  point 
out  any  authentic  case  in  which  it  was  really  of  benefit. 

Much  has  been  written  concerning  the  local  treatment  of 
ecrophulous  tumours  and  ulcers ;  but  we  are  still  very  much 
in  the  dark'with  respect  to  any  efficacious  method.  For- 
merly, the  extirpation  of  the  gland,  or  tumour,  was  advised 
by  all ;  but,  more  lately,  doubts  have  been  started  concerning 
the  propriety  of  the  practice  ;  and,  by  most  practitioners,  it 
is  now  deemed  unnecessary,  if  not  dangerous. 

In  the  writings  of  the  ancients,  as  well  as  many  of  the  old- 
er writers  on  surgery  in  our  own  country,  particularly  in  the 
works  of  Mr.  Wiseman,  this  practice  is  freely  inculcated ; 
and  many  cases  are  detailed  in  which  the  tumour  was  extir- 
pated with  success.  Even  in  the  present  day,  no  surgeon 
dreads  the  consequence  of  removing  scrophulous  joints, 
which,  with  regard  to  the  present  question,  are  to  be  consi- 
dered in  the  same  light  with  the  glands. 

It  is  supposed,  that,  by  extirpating  superficial  tumours, 
the  disease  may  be  transferred  to  some  of  the  more  noble 
parts,  and  produce  a  more  fatal  complaint.  But,  if  it  be  ad- 
mitted that  these  tumours  do  not  appear  as  necessary  parts 
of  scrophula,  as  the  eruption  of  measles  does  of  the  ru- 
beolous  fever,  but  only  as  accidental  circumstances,  or  for- 


165 

tuitous  inflammations,  rendered  tedious  and  specific  by  the 
peculiarity  of  the  constitution,  this  supposition  will  appear 
to  be  groundless.  Even  granting  that  scrophulous  tumours 
did  appear  without  any  local  exciting  cause,  and  were,  in 
every  respect,  similar  to  the  eruption  of  exanthematous 
fevers,  it  will  not  thence  follow,  that  removing  the  local  dis- 
ease, after  it  has  appeared,  will  make  another  part  become 
diseased ;  unless  it  be  said  that  scrophula  depends  upon  a 
particular  morbid  humour,  which,  if  denied  an  outlet  in  one 
place,  must  accumulate  in  another,  which  is  a  supposition  I 
will  not  trouble  myself  to  refute. 

The  arguments,  then,  against  the  excision,  are  not  to  be 
drawn  from  its  danger,  but  from  the  pain  which  it  produces, 
and  from  the  number  of  glands  which  must  frequently  be  re- 
moved, and  which  might  perhaps  be  resolved  without  com- 
ing to  suppuration.  It  is  likewise  at  times  dangerous  to  ex- 
tirpate these  tumours,  on  account  of  their  situation. 

On  the  other  hand,  when  only  one  gland  is  affected,  when 
it  is  superficial,  and  has  continued  so  long,  in  spite  of  our  re- 
medies, that  there  is  little  probability  of  resolving  it,  then, 
by  extirpation,  we  procure  a  speedy  cure,  and  avoid  a  tedious 
disagreeable  ulcer,  and  unseemly  cicatrix.  The  existence 
of  the  scrophulous  inflammation,  and  particularly  the  ulcera- 
tion, has  a  tendency  to  increase  the  scrophulous  diathesis,  or 
peculiar  mode  of  action  of  the  system.  By  cutting  this  short, 
therefore,  we  prevent  that  evil,  and  render  the  system  less 
susceptible  of  the  scrophulous  inflammation,  and  the  chance 
of  communicating  the  disease  to  the  progeny  less. 

It  may  also  be  said,  that  the  wound,  after  the  extirpation, 
might  not  heal  readily ;  but  the  testimony  of  many  writers, 
as  well  as  what  I  have  observed  myself,  convince  me  that 
this  is  not  the  case ;  for  the  readiness  with  which  the  skin 
unites  and  heals,  when  not  previously  diseased,  produces  a 
speedy  cure ;  whereas,  had  the  diseased  gland  remained  he 


166 

low,  and  the  specific  inflammation  been  propagated  to  the 
skin,  the  ulceration  must  have  been  tedious. 

Upon  the  whole,  then,  in  determining  on  the  propriety  of 
extirpation,  we  must  consider  whether  there  be  only  one 
gland  affected,  or  an  incipient  disease  in  a  chain  of  glands; 
and,  if  only  one,  whether  there  be  a  probability  of  this  one 
suppurating;  and  whether  the  advantage  of  an  early  removal 
of  the  affected  part  will  not  be  counterbalanced  by  our  losing 
the  chance  of  restoring  the  part,  and  of  preserving  its  func- 
tions and  utility,  as,  for  instance,  in  scrophulous  inflammation 
of  the  breasts,  testicle,  joints,  &c. 

Caustics  have  been  proposed  with  the  same  view  as  the 
incision ;  but  they  are  more  tedious,  produce  extensive  ulce- 
ration, greater  pain,  and  are  much  less  certain  than  the  ope- 
ration. 

Issues  are  recommended  as  a  general  remedy,  to  act  as  a 
drain  to  the  constitution,  and  to  render  the  drying  up  of  the 
ulcer  safe.  In  this  point  of  view,  they  appear  to  be  altoge- 
ther useless  and  unnecessary ;  but,  when  employed  as  part  of 
the  local  treatment,  they  are  much  more  useful.  The  be- 
nefit arising  from  the  use  of  issues,  in  the  cure  of  scrophu- 
lous inflammation  of  the  bones  and  joints,  is  now  so  fully 
established,  by  the  practice  of  every  surgeon,  that  it  is 
useless  to  insist  upon  it  here.  In  these  cases,  it  is  necessary 
to  insert  the  issue,  which  is  generally  made  with  caustic,  as 
directly  over  the  affected  part  as  possible ;  and  the  size  of 
this  issue  ought  in  general  to  be  correspondent  to  the  extent 
of  the  disease.  There  are  two  circumstances  which  greatly 
tend  to  render  this  practice  efficacious,  and  which  ought  to 
be  fully  attended  to :  First,  that  the  disease  be  allowed  to 
gain  as  little  ground  as  possible  before  the  insertion  of  the 
issue,  or  that  the  issue  be  inserted  as  early  after  the  disease 
is  observed  as  the  patient  will  permit.  Second,  that,  during 
he  cotntintiance  of  the  issue,  every  circumstance  be  avoided 


167 

which  may  counteract  its  use,  such  as  much  use  of  the  joint, 
or  other  species  of  irritation.  In  diseases  of  the  lower  ex- 
tremities, therefore,  whatever  exercise  produces  pain  must 
be  carefully  avoided ;  and,  for  the  same  reason,  in  diseases 
of  the  spine,  proper  contrivances  to  relieve  the  diseased  bone 
from  pressure  are  necessary  to  be  conjoined  with  the  issue. 
It  sometimes  happens,  that  matter  has  either  formed  before 
the  insertion  of  the  peas,  or  some  time  afterward.  In  this 
case,  it  either  comes  to  be  discharged  by  an  opening  through 
the  ulcerated  surface,  or  issue,  or  it  bursts  at  a  more  de- 
pendent part.  In  the  first  situation,  no  change  of  treatment 
is  necessary ;  in  the  second,  it  is  of  service  to  insert  a  pea 
over  the  mouth  of  the  aperture,  which  has  a  tendency  to  heal 
the  part  below,  and  prevent  the  formation  of  a  tedious  sinus. 
When  the  part  becomes  free  from  pain,  and  the  soft  parts 
have  subsided  in  their  swelling,  and  matter  does  not  appear 
to  be  forming,  or  does  not  continue  to  be  formed,  if  it  had 
already  been,  secreted,  we  may  consider  that  the  effect  of 
the  issue  is  now  produced,  and  may  begin  gradually  to  dimi- 
nish its  size. 

Issues,  employed  as  a  local  remedy,  have  hitherto  been 
chiefly  used  in  diseases  of  the  bones  and  joints,  and  some- 
times in  scrophulous  affections  of  the  liver,  or  lungs ;  but 
it  is  reasonable  to  suppose  that  they  ought  likewise  to  be  use- 
ful in  the  cure  of  enlargements  of  the  glands,  and  other  scro- 
phulous tumours,  if  inserted  in  tb^  immediate  vicinity  of  the 
part.  The  only  objection  to  their  use  is  the  cicatrix  which 
they  leave,  and  which,  in  certain  situations,  we  would  wish 
to  avoid.  When  the  tumour  is  thickly  covered  with  the  in- 
teguments, the  issue  may  be  made  directly  over  it,  by  means 
of  a  blister,  kept  open  by  savine  ointment,*  or  any  other  ir- 


*  This  ointment  may  be  prepared  by  macerating  one  part  of  recent  savine 
feaves  bruised,  in  four  parts  of  ung.  resinos. ;  it  is  then  to  be  strained. 


lea 

ritating  preparation;  but,  when  the  tumour  is  thinly  covered, 
thi?=  will  not  succeed,  as  the  inflammation  consequent  to  the 
iflsertion  of  the  issue  will  be  communicated  to  the  gland 
which  is  in  immediate  contact  with  the  ulcerated  surface. 
In  this  case,  a  small  pea  issue,  or  seton,  may  be  inserted  by 
the  side  of  the  tumour.  In  scrophulous  inflammation  of  the 
glands  of  the  neck,  this  remedy  is  not  advisable,  owing  to 
the  scar  which  it  leaves  ;  but  in  affections  of  the  mammae,  and 
some  other  parts,  it  may  be  useful. 

Blisters,  frequently  repeated,  are  sometimes  in  slighter 
cases  of  affections  of  the  joints,  used  in  place  of  issues. 

Preparations  of  lead  are  frequently  employed,  and,  where 
the  tumour  is  painful,  are  often  of  service.  When  the  lym- 
phatic glands  are  inflamed,  a  saturnine  solution,^  applied  cold 
to  the  part,  by  means  of  a  compress  of  linen,  and  frequently 
renewed,  has  a  tendency  to  abate  the  pain,  and  resolve  the  in- 
flammation. These  solutions  are  sometimes  employed  warm, 
particularly  in  affections  of  the  bones  or  joints  ;  but  they  do 
not,  in  these  cases,  seem  to  have  any  considerable  superiority 
over  fomentations  with  warm  water. 

Cloths  dipped  in  cold  water,  sea-water,  or  weak  vegetable 
acids,  have  also  been  used,  and  have  a  tendency  to  abate  pain, 
but  are  inferior  to  the  saturnine  solution. 

Ether,  applied  with  a  pencil  to  the  part,  is  also  sometimes 
of  service. 

Sea  salt,  mixed  with  bile,  has  been  recommended,  but  has 
very  little  effect. 

Camphorated  liniment  is  very  frequently  used,  in  which 
case  the  part  is  generally  kept  warm  with  flannel.  It  does 
not,  however,  appear  to  possess  any  very  great  power  of  dis- 


The  following  may  be  used  for  thi9  purpose : 
R.  CerufF.  Acetat  drachmam  unam. 

Aq.  Eosar.  uacias  ©ct».    Solve,  deia  cola. 


169 

cussing  these  tumours ;  but  the  friction  which  is  made  use  of 
with  these  sometimes  hastens  the  removal  of  these  tumours, 
and  may  be  usefully  alternated  with  the  use  of  the  saturnine 
lotion.  A  mixture  of  ether  and  linimentum  opiatum  may  be 
employed  for  the  same  purpose. 

Hemlock  poultices  were  at  one  time  in  repute,  but  they 
have  now  lost  their  character. 

By  these  means,  even  after  a  small  quantity  of  matter  is 
formed  in  the  gland  or  tumour,  we  may  discuss  the  tumour, 
or  make  it  less ;  but,  if  the  quantity  of  matter  should  continue 
to  augment,  we  may  consider  resolution  as  out  of  the  ques- 
tion.  Our  object  must  then  be  to  bring  the  part  to  suppura- 
tion as  quickly  as  possible ;  because  we  not  only  thus  shorten 
a  process  which  must  be  completed  before  the  parts  can  be 
healed,  but  also  render  the  ulcerative  action  more  healthy, 
and  easier  induced ;  for  the  more  quickly  that  the  suppura- 
tive action  is  performed,  the  sooner  does  the  ulcerative  ac- 
tion take  place,  and  the  more  vigorous  is  it,  provided  that 
no  new  cause  rend&hit  unhealthy,  as  has  formerly  been  men- 
tioned. 

This  advice,  however,  must  not  be  adopted  without  some 
exceptions,  and  must  be  chiefly  confined  to  affections  of  the 
glands  and  cellular  substance,  and  ought  not  to  be  extended 
to  the  joints.  In  these  cases,  even  although  a  small  quanti- 
ty of  matter  form,  we  ought  still  to  endeavour  to  prevent 
general  suppuration,  and  the  bursting  of  an  abscess  ;  because 
this  would,  instead  of  accelerating  the  cure,  as  is  frequently 
the  effect  in  the  other  case,  be  attended  with  dangerous 
consequences ;  we  must  therefore  rather  continue  the  use  of 
the  issues,  and  endeavour  to  procure  the  absorption  of  what 
matter  is  already  formed. 

The  means  employed  for  promoting  suppuration  were 
formerly  poultices  of  lily  roots,  honey,  &c.  alternated  with 
fomentations  prepared  from  pomegranate  seeds,  and  myrrh, 


170 

and  cypress  leaves,  or,  occasionally,  stimulating  plasters ; 
but  now  the  common  bread  and  milk  poultice  is  advan- 
tageously substituted  in  place  of  these  remedies.  When 
the  process  is  very  tedious,  electricity  is  useful  along  with 
the  poultices. 

When  these  tumours  have  suppurated  freely,  and  an  ab- 
scess occupies  the  whole  of  the  gland,  it  is  useful  to  evacuate 
the  matter  by  a  small  opening  with  a  lancet,  if  there  be  no 
appearance  of  the  abscess  bursting  quickly,  and  the  sooner 
this  is  done  the  better.  When  this  is  done,  a  poultice  should 
be  applied  until  next  day,  the  part  is  then  to  be  wiped  clean 
and  dry,  and  a  small  bit  of  lint,  spread  with  simple  ointment, 
applied  on  the  orifice.  The  surrounding  red  skin  is  to  be 
dusted  with  powdered  cerussa,*  and  then  covered  with  dry 
lint.  A  compress  is  to  be  laid  over  the  whole,  and  moderate 
pressure  employed.  These  applications  are  to  be  renewed 
every  day,  or  twice  a-day,  according  to  the  quantity  of  the 
discharge,  and  other  circumstances  ;  and,  at  each  dressing, 
the  parts  may  be  bathed  with  spirit  of  &ne.  If  this  mode 
of  dressing  does  not  produce  a  cure,  but  the  opening  en- 
larges, and  the  surface  ulcerates,  we  must  then  employ  the 
dressings  for  a  scrophulous  sore. 

When,  notwithstanding  the  use  of  issues,  matter  is  formed 
in  joints,  or,  when  these  fail  to  procure  the  absorption  of  what 
was  formed  before  they  wTere  introduced,  then  one  of  two 
things  must  happen;  either  the  abscess  must  be  punctured, 
or  it  must  be  allowed  to  burst  of  its  own  accord.  In  gene- 
ral, I  believe,  it  is  most  advantageous  to  allow  the  abscess  to 
burst  without  any  interference,  except  the  continuance  of 
the  issue,  or  the  establishment  of  such  new  ones  as  circum- 


*  Keeping  this  skin  dry  has  a  tendency  to  prevent  ulceration,  aud  abate  the 
redness  and  inflammation.  The  cerussa  may  sometimes  be  advantageously  mixed 
with  an  eighth  part  of  powdered  camphor,  which  promotes  the  removal  of  the 
superficial  inflammation. 


171 

stances,  particularly  the  situation  of  the  pain,  may  point  out. 
If,  however,  it  were  at  any  time  deemed  proper  to  evacuate 
the  matter,  this  ought  to  be  done  with  a  small  trocar,  at  dif- 
ferent times,  in  the  manner  recommended  by  Mr.  Aberncthy 
for  the  cure  of  lumber  abscess.  This  is  infinitely  preferable 
to  the  barbarous  practice  which  even  some  surgeons  high  in 
reputation  advise  and  make  use  of,  I  mean  the  insertion  of  a 
seton  through  the  abscess  of  the  joint.* 

"When  the  scrophulous  suppuration  ends  in  the  ulcerative 
action,  the  cure  is  generally  tedious.  It  is  even  doubted  by 
some  how  far  it  is  safe  to  attempt  a  speedy  termination  to 
the  ulcer,  as  it  is  supposed,  that,  in  this  case,  the  disease 
may  be  driven  to  some  other  part :  And  so  fearful  are  they 
of  this  dreadful  event,  that  they  are  careful,  by  issues  and 
new  artificial  sores,  to  continue  the  discharge  after  the  ori- 
ginal ulcer  is  healed. 

If  I  have  been  right  in  my  view  of  this  disease,  it  will  ap- 
pear, that  this  reasoning  is  false,  and  that  the  practice  is 
both  useless  and  troublesome.  Even  those  who  propose  and 
defend  the  practice,  do  so,  not  upon  the  principles  of  reason 
and  judgment,  or  from  logical  deductions  from  the  theory 
which  they  give  of  the  disease,  but  upon  imaginary  appre- 
hensions. We  find,  for  instance,  Mr.  Bell  saying,  that, 
"  till  the  disease  is  eradicated  from  the  habit,  all  that  should 
in  general  be  done  to  the  sores,  is,  to  give  as  free  and  open 
vent  to  the  matter  as  possible."!  From  this,  we  should, 
without  doubt,  expect,  that  he  considered  scrophula  as  de- 
pendent upon  some  peculiar  humour  which  was  to  be  ex- 
pelled ;  but  just  before  we  are  told,  that  this  disease  depends 
upon  debility,  particularly  of  the  lymphatic  system ;  a  con- 
dition which  it  is  not  customary  to  talk  of  eradicating,  or 


*  Bell  on  Ulcers,  p.  471. 
t  Bell  on  Ulcers,  p.  427. 

vol.  ii ;  v 


172 

footing  out,  or  expelling.  Upon  the  common  principles  ol 
reasoning,  Mr.  Bell  ought  only  to  have  forbid  healing  the 
sores,  until  the  system  was  strengthened,  otherwise  the 
weakness  would  be  driven  or  determined  to  some  other  part. 

Moderate  pressure,  by  means  of  adhesive  plaster,  con- 
joined with  the  application  of  cold  water,  is  one  of  the  best 
remedies  for  the  mild  scrophulous  ulcer,  when  it  is  situated 
so  that  this  can  be  used.  When  it  is  not,  then  dusting  the 
part  thickly  with  cerussa,  containing  a  sixth  part  of  powdered 
alum,  may  be  had  recourse  to.  A  piece  of  dry  lint  is  next 
to  be  applied,  and  a  compress  bound  down  with  such  pres- 
sure as  can  be  used.  It  is  sometimes  useful  to  dip  the  com- 
press in  cold  water,  and  renew  it  frequently. 

The  ceratum  e  lapide  calaminari  forms  a  very  good  dress- 
ing for  this  sore,  when  it  is  intended  to  leave  it  to  follow  its 
own  course. 

As  a  stimulant,  the  unguentum  resinorum,  either  alone, 
or  mixed  with  red  precipitate,  is  often  used ;  but  it  seldom 
is  of  service,  and  often  makes  the  sore  irritable.  If,  however, 
the  ulcer  become  very  indolent,  this,  or  the  citrine  ointment, 
properly  diluted,*  may  be  of  service.  The  same  may  be 
said  of  the  other  common  stimulating  applications. 

Poultices,  made  of  bread  and  sea  water,  have  been  recom- 
mended, but  seem  to  possess  little  power  of  accelerating  the 
cure. 

Solutions  of  alum,  of  blue  vitriol,  corrosive  sublimate,f  of 
the  nitrites  of  copper,  bismuth,  and  silver,  are  sometimes 
Useful  to  wash  the  sore  with. 


*  This  application  forms  a  very  useful  remedy  for  the  scrophulous  ulceration  of 
flie  eye-lids,  which  we  so  frequently  meet  with. 

f  This  substance  is  the  basis  of  a  celebrated  lotion  for  the  face,  which  k  some- 
times useful  in  chronic  pustules,  which  are  frequently  of  a  scrophulous  nature.  It 
promotes  suppuration,  the  pustule  then  scabs,  and,  when  thii  falls  off,  the  part  is 
sometimes  found  sound  below.  It  in  made  by  dissolving  corro^m-  sublimate  in  as 
emulsion  of  bitter  almonds. 


173 

The  recent  leaves  of  the  wood  sorrel  bruised,  and  applied 
raw  to  the  sore,  is  sometimes  useful.  The  same  may  be 
said  of  cloths  dipped  in  lemon  juice,  or  vinegar  and  water. 

Saturnine  ointment  is  much  employed  by  some,  for  abating 
heat  and  pain ;  but  is  inferior  to  compresses  dipped  in  cold 
water. 

Sometimes  only  the  anterior  part  of  a  scrophulous  tumour 
suppurates  and  ulcerates,  and  the  deeper  part  of  it  remains 
swelled  and  hard.  Jn  this  case,  the  bottom  is  generally  co- 
vered with  a  slough,  which  comes  slowly  away  piecemeal, 
and  is  renewed  for  some  time,  until  the  tumour  subsides, 
partly  by  sloughing,  partly  by  absorption,  and  partly  by  the 
subsidence  of  the  remaining  inflammatory  action.  In  this 
case,  sprinkling  the  surface  lightly  with  precipitate,  or  blue 
vitriol,  is  of  service  ;  and  this  may  be  alternated  with  the 
common  warm  poultice.  When  the  surface  becomes  cleaner, 
dry  lint  forms  a  very  good  dressing ;  and  this  may  be  cover- 
ed with  a  pledget  of  linen  spread  with  cerate.  Afterwards 
pressure  is  useful. 

The  irritable  overacting  sore,  or  what  has  been  called  the 
struma  maligna,  is  very  difficult  to  manage,  especially  as  it 
is  frequently  connected  with  a  diseased  state  of  the  bones  or 
tendons  below. 

The  hepatized  ammonia,  diluted  in  the  manner  formerly 
iuentioned,  or  simple  ointment,  mixed  with  opium,  are  some- 
times of  use. 

Poultices  of  bitter  almonds,  beat  up  with  a  little  olive  oil 
into  a  fine  pulp,  and  then  warmed,  occasionally  relieve  the 
pain,  and  make  the  ulcer  more  healthy. 

Carrot  poultices,  or  warm  poultices  made  of  bread  and 
strong  decoction  of  camomile  flowers,  are  also  sometimes  of 
use. 

Carbonic  acid  gas,  or  carbonated  hydrogene,  are  some- 
times of  temporary,  rarely  of  permanent  advantage. 


174 

Anodynes,  internally,  are  useful  here,  as  in  other  painful 

sore  ■ 

In  all  cases  of  scrophujous  inflammation  or  ulceration,  it  is 
useful  to  exhibit,  along  with  the  proper  local  treatment,  such 
internal  medicines,  and  to  attend  to  the  constitution,  in  such 
respects  as  may  be  deemed  proper.  Upon  these  points  I 
have  already  made  some  observations. 

When  the  local  disease  cannot  be  cured,  and  has  induced 
the  scrophulous  hectic ;  when  this  cannot  be  removed  by 
the  means  commonly  employed,  and  which  have  been  men- 
tioned in  the  dissertation  on  simple  inflammation,  then  the 
diseased  part  must  be  removed,  if  its  situation  permit.  This 
must  not,  however,  be  rashly  done,  but  must  be  delayed  un- 
til we  ascertain  that  our  remedies,  general  and  local,  (which 
must  be  used  with  assiduity  and  care)  are  of  no  avail.  It  is 
not  sufficient  that  the  hectic  continues,  and  that  other  ap- 
pearances are  almost  stationary ;  they  ought  to  be  augment- 
ing, in  order  to  justify  amputation  of  a  useful  and  important 
part;  because  every  practitioner  must  have  observed  the 
recoveries  which  take  place,  even  after  the  hectic  fever  has 
made  considerable  progress.  On  the  other  hand,  we  must 
not  allow  the  constitution  to  suffer  too  much,  but  must  in- 
terfere, whenever  we  perceive  that  our  labours  are  fruitless, 
and  that  the  hectic  is  regularly  and  progressively  increasing, 
and  the  strength  sinking.  When  this  is  observed,  the  only 
chance  for  life  is  an  operation ;  and  every  day  this  is  delay- 
ed adds  to  the  risk  attending  it  ;  for  there  is  a  degree  of  in- 
jury, more  than  which  the  constitution  cannot  sustain,  and 
which  will  prove  fatal,  even  although  the  exciting  cause  be 
removed.  To  fix  the  proper  period  requires  judgment  in 
the  surgeon ;  but  he  may  be  enabled  to  do  so,  by  attending 
carefully  to  the  state  of  all  the  symptoms ;  for  whenever 
these  continue  progressively  to  become  worse,  and  have  re- 
duced the  patient  already  to  a  state  of  weakness,  which  can- 


175 

not  be  much  increased  without  danger,  he  may  consider  it 
as  impossible  to  delay  amputation  longer  with  any  hopes  of 
success. 

Having  made  these  observations  on  this  species  of  scro- 
phula,  I  shall  now  conclude,  by  shortly  mentioning  the  mode 
of  treatment  adopted  by  the  older  practitioners. 

Bleeding,  which  at  first  was  made  use  of  according  to  the 
custom  of  the  day,  was  soon  laid  aside,  on  observing,  that,  in 
many  cases,  it  was  manifestly  hurtful,  and  in  every  instance 
useless.  But  although  the  plan  of  general  depletion  was 
given  up,  yet  local  evacuations  were  much  insisted  on  ;  for 
they  held  it  as  absolutely  requisite,  that  the  brain  should  be 
purged  of  its  pituita,  (the  redundancy  of  which  produced  the 
disease)  by  errhines,  fomentations  to  the  ears,  and  the  appli 
cation  of  issues  and  sinapisms  to  the  head.  The  stomach 
was  cleared  of  viscosities,  by  emetics  of  mustard  or  broom 
seed  ;  the  bowels,  by  aloes ;  and  the  skin  and  kidneys,  by 
sudorifics  and  diaphoretics. 

Having  thus  procured  a  sufficient  evacuation,  the  patient 
was  desired  to  smell  a  pomum  odoratum,  composed  of  styrax, 
amber,  myrrh,  aloes,  and  many  other  ingredients ;  the  va- 
pours of  which  were  supposed  to  get  up  to  the  anterior  ven- 
tricles of  the  brain,  and  dry  them.  Hunger  and  thirst,  by 
drying  the  juices,  were  decreed  to  be  salutary.  Every 
thing  was  rendered  nauseous  with  medicine.  The  bread 
was  seasoned  with  anise  and  fcenugrek  seeds,  and  the  drink 
consisted  of  decoctions  of  guaiac  and  mastic  wood,  which 
last  was  "  a  friend  to  the  brain  and  viscera."*  As  a  condi- 
ment to  these  medicated  meals,  Arnoldus  de  Villa  Nova 
treated  his  patients  to  the  burnt  sponge,  mixed  with  salt  and 
pepper. 


*  Laurent.  <lc  Strum.  IVat.  p.  67. 


116 

But  these,  and  indeed  all  the  medicines  yielded  by  the 
materia  medica,  were  considered  as  trifling,  and  of  no  avail, 
when  compared  to  the  miraculous  power  possessed  by  the 
king,  who,  with  one  touch  of  his  hand,  could  banish  this 
dreadful  disorder,  and  dry  up  all  the  sores.  So  valuable  did 
this  royal  prerogative  appear  in  the  eyes  of  many,  that  it 
became  a  national  controversy,  whether  it  belonged  to  the 
French  or  English ;  whilst  the  Romish  and  Protestant 
churches  reciprocally  urged  this  prerogative  of  the  king  of 
the  country  where  they  were  established,  as  a  manifestation 
from  heaven  of  the  justice  of  their  cause. 

In  France,  the  king  touched  publicly,  at  four  stated  feaste 
in  the  year,  preparing  himself  the  day  before  by  prayer  and 
fasting;  then  entering  the  apartment,  where  the  sick  were 
arranged,  the  patients  were  individually  presented  by  the 
chief  physician  to  his  majesty,  who  placed  his  hand  upon 
their  head,  pronouncing  these  words,  "  Le  Roy  te  touch,  et 
Dieu  te  guarit."  The  sick  then  retire,  and  soon  find  a 
manifest  amendment-  "  In  some  the  ulcers  dry  up ;  in 
others  the  swellings  diminish ;  and,  wonderful  to  relate,  in  a 
few  days,  more  than  500  out  of  1000  are  perfectly  cured  !" 
"  Hie  hcerant  philosophi,  coecutiunt  medici,  stupet  propha- 
num  vulgus." 

Upon  reading  these  accounts,  we  smile  at  the  credulity  of 
mankind;  but  we  pity  them,  when  we  learn,  that  near  a 
thousand  every  year  made  weary  and  expensive  pilgrimages, 
from  very  distant  countries,  to  purchase  this  imaginary  be 
fcefit. 


DISSERTATION  VI. 


OX    THE    CANCEROUS    INFLAMMATION. 


The  cancerous  inflammation  generally  comes  in  slowly, 
in  some  glandular  part,  which  becomes  rather  harder,  and 
somewhat  larger,*  than  it  ought  to  be  ;  but  the  pain,  for  the 
most  part,  at  first  is  trifling.  By  degrees,  both  the  hardness 
and  swelling  increase,  and  a  pain,  like  the  pricking  of  nee- 
dles, is  felt  in  the  part.  This  pain,  after  some  time,  be- 
comes more  violent,  darting  through  the  whole  of  the  gland, 
and  leaving  a  sensation,  as  if  the  part  had  been  rudely  wrung 
or  twisted.  The  tumour  still  remains  moveable  under  the 
skin,  which  is  of  the  natural  colour  ;  but  when  the  disease 
has  continued  a  little  longer,  a  greater  degree  of  inflammation 
lakes  place,  and  adhesions  are  formed  betwixt  the  skin  and 
the  gland,  or  the  gland  and  the  parts  below,  at  the  same 
time  that  the  pain  becomes  more  continued.  The  skin  now 
becomes  puckered,  or  drawn  inward,  and  of  a  dirty  or  leaden 
hue,  which  in  time  acquires  more  of  the  red,  but  is  never  of 
a  bright  colour.  The  veins  are  varicose,  and  the  tumour  is, 
with  difficulty,  moveable.  When  the  skin  becomes  red,  we 
may  be  able  to  discern  a  superficial  fluctuation,  which  pro- 
ceeds from  part  of  the  gland  forming  an  abscess.f      This  at 

*  Although  the  affected  gland  becomes  rather  larger,  yet  the  surrounding  cel.- 
lular  substance  sometimes  diminishes,  and  the  neighbouring  glacdi  are  rather  con- 
tracted, in  which  case  the  part  seems  to  be  shrunk. 

t  This  abscess  sometimes,  though  very  rarely,  occupies  the  whole  of  the  gland,. 
ha*  oftener  only  a   part  of  it:  aoH  if  the  gland  be  largf,  (here  arc;  sometime* 


178 

last  bursts,  and  discharges  a  thin  yellowish  matter,  which 
frequently  oozes  out  in  very  considerable  quantity  ;  the 
orifice  enlarges,  and  the  sore  penetrates,  for  a  little  way 
downward,  pretty  rapidly,  and  the  edges  become  hard,  and 
overlap  a  small  part  of  the  disk  of  the  sore ;  but,  soon  after 
this,  a  fungus  rises  up ;  and  although,  in  some  places,  the 
ulcer  may  become  deeper,  yet  its  chief  progress  is  later- 
all}. 

The  cancerous  ulcer  increases  more  or  less  rapidly,  and 
is  soon  attended  with  a  burning  pain ;  the  surface  is  unequal, 
excavations  appearing  in  some  parts,  whilst  in  others  a  fun- 
gus rises  up.  The  colour  is  brown,  but  glistening  or  fiery. 
The  granulations  very  soft  and  indistinct.  A  thin  ichor,  of 
an  abominable  fcetor,  is  discharged  in  great  plenty,  mixed 
with  blood  ;  whilst,  in  many  parts,  small  pellicles,  like  lym- 
phatic exudations,  cover  the  sore.  The  surrounding  skin 
is  of  a  dark  purple  colour,  and  the  adjacent  parts  very  hard. 
The  margins,  which  at  first  were  overlapping  the  sore,  in 
the  course  of  a  few  days  are  uniformly  elevated,  and  fre- 
quently retorted  and  unequal,  as  if  they  had  been  bitten  by 
an  animal ;  and  over  these  the  fungus  frequently  shoots  or 
protrudes,  so  that  the  sore  assumes  the  appearance  of  a  cauli- 
flower. This  ulcer  bleeds  a  little  upon  the  slightest  touch, 
so  that  at  every  dressing  the  cloths  are  generally  bloody ; 
but,  at  times,  this  bleeding  is  more  alarming,  proceeding 
from  the  bursting  of  the  diseased  veins.  These  hemorr- 
hages are,  in  some  instances,  very  frequent,  and  reduce  the 
patient  to  the  greatest  weakness.  Sometimes  they  sudden- 
ly relieve  the  unhappy  persons  from  all  their  wo. 

Some  time  after  the  abscess  forms,  and  frequently  before 
ulceration  takes  place,   the  neighbouring  lymphatic  glands 


several  abscesses,  of  considerable  size,  which  form  unconnectedly  with  each  otber, 
and  burst  separately. 


179 

swell,  and  become  affected  with  a  similar  action,  and  follow 
the  same  course  with  the  original  sore ;  only  in  them  the  pro- 
gress is  generally  more  rapid. 

After  ulceration  takes  place,  sometimes  before  it,  if  the 
abscess  be  considerable,  hectic  fever  takes  place ;  the  coun- 
tenance becomes  sallow  and  unhealthy ;  the  pulse  quickens, 
and  becomes  small  and  sharp ;  the  strength  fails  ;  night 
sweats  come  on,  and  colliquative  diarrhoea  hastens  death. 

The  parts  in  which  cancer  most  frequently  appears,  are 
the  under  lip,  the  breasts  of  women,  and  the  testicles  of 
men  :  But  there  is  no  one  part  of  the  body  in  which  it  may 
not  occur,  although  most  frequently  it  is,  in  its  original  at- 
tacks, confined  to  secreting  glands. 

In  the  breasts,  parotid  glands,  and  some  other  conglome- 
rate glands,  the  disease  begins  as  has  been  described ;  but  on 
the  skin,  and  in  some  other  parts,  the  progress  is  somewhat 
different.  The  skin,  particularly  that  of  the  face,  is  apt  to 
have  a  small  chronic  pustule  formed  on  it,  by  the  inflamma- 
tion of  one  of  the  sebaceous  glands,  which,  by  degrees,  be- 
comes harder,  firmer,  and  more  elevated.  Soon  afterwards, 
it  becomes  rough,  and  of  a  warty  appearance :  It  then  ul- 
cerates on  the  surface.  This  is  covered  with  a  scale  or 
scab,  which  repeatedly  falls  off,  and  forms  again  upon  the 
part,  until  it  assume  the  appearance  and  character  of  the 
cancerous  sore.  But,  more  frequently,  the  disease  is  not  al- 
lowed to  follow  this  progress,  the  wart  either  being  rubbed 
off  accidentally,  or  removed  by  ignorant  persons.  The 
part  then  forms  a  superficial  ulcer,  which  is  slightly  hollow- 
ed. It  is  of  a  glistening  flabby  appearance,  and  the  margins 
are  hard,  tumid,  and  a  little  turned  back  :  But  after  the  dis- 
ease has  continued  some  time,  the  flabby  appearance  of  the 
sore  is  converted  into  fungus.  We  may,  therefore,  from 
this,  and  other  cases,  conclude,  that  cancerous  ulcers,  which 

VOI,.    II.  7. 


180 

are  formed  without  previous  abscess,  form  fungus  more  slow- 
ly than  those  which  are  formed  with  them. 

When  the  lips  become  cancerous,  there  is  generally  first 
perceived  an  indurated,  lump,  of  greater  or  less  bulk.  The 
skin  over  it  becomes  tender,  frets,  and  is  covered  with  a 
scurf  or  scab,  which  gradually  becomes  elevated.  Part  falls 
occasionally  off,  but  it  is  soon  replaced.  This  by  degrees 
extends  itself  over  the  prolabium,  and,  after  some  time,  falls 
off  entirely,  leaving  the  part  with  all  the  common  characters 
of  the  cancerous  ulcer.     The  pain  is  burning. 

When  the  testicle  becomes  cancerous,  it  sometimes  follows 
the  common  course  of  cancer  in  other  glands,  beginning  with 
hardness  and  shooting  pain  in  some  part  of  the  testicles  or 
epidydimis,  which  gradually  forms  an  abscess,  and  ulcerates. 
But,  at  other  times,  soon  after  the  testicle  becomes  diseased, 
an  effusion  takes  place  within  the  tunica  vaginalis.  In  this 
case,  the  disease  of  the  testicle  becomes  complicated  with 
hydrocele.  It  is  distinguished  by  our  feeling  the  hardness 
of  the  epidydimis  behind,  or  the  hardness  and  inequality  of 
the  testicle,  when  the  water  is  drawn  off.  It  likewise,  after 
some  continuance,  becomes  more  painful  than  a  common 
case  of  hydrocele.  If  the  testicle  be  not  extirpated  in  due 
time,  the  cord  becomes  hard  and  swelled,  and  comes  to  ul- 
cerate. 

Cancer  in  the  penis  generally  begins  by  a  kind  of  warty- 
tHmour,  and  follows  the  course  of  cancer  in  the  face.  Some- 
times the  penis  becomes  just  like  a  cauliflower,  a  large  fun- 
gus extending  from  its  ulcerated  extremity. 

The  uterus,  in  elderly  women,  is  very  frequently  affected 
with  cancer.*     It  begins  with  a  feelin«;  of  weight  and  unea- 


*  It  has  been  said,  that  genuine  cancer  is  very  rare  in  the  uterus,  and  that  the. 
cases  which  pass  for  such  are  phagedenic.  But  although  the  uterus  may  be  affect- 
ed with  scrophulous  inflammation,  and  phagedenic,  as  well  as  some  other  specific 
arTecti^r)?,  yet  it  must  be  admittf-d,  from  an  .examination  of  case?,  that  the  uterus 


131 

siness  in  the  lower  part  of  the  belly,  and  the  natural  dis 
charge  of  the  parts  is  increased,  so  that  the  disease  passes 
for  fiuor  albus.  By  examination,  however,  we  may  general- 
ly discover  a  hardness,  and  sometimes  an  inequality,  about 
the  os  uteri,  and  may  discover  the  uterus  to  be  unequally 
enlarged.  After  some  time,  ulceration  takes  place,  and  mat- 
ter, mixed  with  a  bloody  fluid,  is  discharged.  Occasionally, 
considerable  hemorrhages  take  place,  which  are  not  unfre- 
quently  confounded  with  menorrhagia  ;  but  it  may  be  dis- 
tinguished by  the  continued  discharge  of  a  bloody  sanies 
during  the  intervals  of  the  hemorrhage ;  by  the  continual 
pain,  and  especially  by  our  feeling  the  projection  of  the  os 
uteri  into  the  vagina,  in  some  places  hard,  and  in  others  soft, 
but  rough,  which  shows  ulceration.  After  some  time,  the 
glands  about  the  vagina  swell ;  and  that  canal,  in  many 
places,  becomes  considerably  straitened.  Hectic  terminates 
the  sufferings  of  the  patient.  On  opening  the  body,  we  find 
the  uterus  generally,  though  not  always,  considerably  enlarg- 
ed, with  abscess  and  ulcers  in  different  parts  of  its  substance. 
These  ulcers,  as  well  as  those  of  the  ovarium,  and,  so  far  as 
1  know,  every  gland  in  the  internal  cavities  of  the  body, 
have  a  less  tendency  to  fungate,  than  cancerous  ulcer  on  the 
surface  of  the  body. 

When  inflammation  attacks  any  organ,  or  part  of  the  body, 
and  leaves  a  chronic  tumour,  this  may  assume,  as  will  after- 
wards be  mentioned,  a  new  inflammation,  and  may  become 
affected  with  cancer  ;  though  it  more  frequently  happens, 
that  it  assumes  the  pseudo-cancerous  action.  The  symp- 
toms and  progress  of  cancer  are  much  the  same  here  as  in 
the  breast. 

When  the  eye  becomes  cancerous,  it,  unless  the  disease 
begins  in  one  of  the  glands,  such  as  the  lachrymal,  or  those 


is  very  frequently  attacked  with  true  cancer.    Its  substance  is  found  enlarged* 
hard,  and  containing  cancerous  abscesses  in  different  parts. 


182 

of  Meibomius,  is  first  of  all  affected  with  simple  inflamma- 
tion, which  destroys  the  whole  texture  of  the  eye,  and  makes 
it  of  a  different  structure,  rather  resembling  a  confused  mass 
than  a  well  organized  body.  The  lucid  cornea  becomes 
opake,  and  protrudes ;  the  eye  enlarges,  is  affected  with  a 
violent  deep-seated  pain,  and  at  last  bursts,  generally  on  the 
apex :  From  this  a  fungous  substance  protrudes,  which  mani- 
fests all  the  symptoms  of  the  cancerous  ulcer,  and  in  a  short 
time  arrives  at  a  great  size. 

When  the  nose  becomes  cancerous,  the  disease  either  be- 
gins on  the  outside,  with  a  small,  tumour  or  wart,  as  in  other 
parts  of  the  face,  or  within,  by  a  firm  and  somewhat  painful 
polypous  projection,  which  frets  on  the  surface,  and  soon  as- 
sumes the  cancerous  ulceration. 

The  diagnosis  of  this  disease  is  of  the  utmost  importance  ; 
because  if  we  mistake  cancer  for  some  other  disease,  we  not 
only  neglect  the  proper  practice,  but  frequently  are  led  to 
prescribe  remedies  which  do  infinite  harm.  If,  on  the  con- 
trary, we  mistake  another  disease  for  cancer,  we  neglect  the 
necessary  means  of  cure,  and  may  even  be  Jed  to  extirpate 
a  part  which  might  be  easily  cured  by  gentler  treatment. 

Cancer  may  be  confounded  with  scrophula,  syphilis,  and 
some  other  affections,  which  have  received  no  particular 
name. 

There  is  an  affection*  which  begins  like  cancer,  by  a  hard 
schirrus,  either  of  a  gland,  or  still  more  frequently  of  one  of 
the  chronic  tumours,  which  has  been  already  mentioned  as 
succeeding  slow  inflammation.  This  remains,  for  a  conside- 
rable time,  hard,  and  free  from  pain,  and  there  is  no  pucker- 
ing of  the  skin  over  it.  By  degrees,  some  part  of  the  sur- 
face becomes  of  a  purple  or  livid  colour,  and  ulcerates. 


*  To  this  specific  affection,  we  may  give  the  name  of  pseudo-cancer,  for  wnnr 
of  a  better  designation. 


183 

This  ulcer  remains  long  superficial ;  the  edges  arc  hard  and 
rounded ;  the  discharge  is  thin ;  the  surface  is  gloss}',  and 
no  distinct  granulations  can  be  seen  ;  the  pain  is  slightly 
smarting,  but  not  burning,  and,  instead  of  being  fungous,  the 
sore  is  slightly  hollowed  out  below  the  level  of  the  surround-1 
ing  skin.  By  the  continuance  of  this  affection,  the  gland  is 
apt  to  shrink  and  diminish  in  size  ;  and  generally  where  this 
takes  place,  the  sore  contracts  and  heals  with  a  very  pucker- 
ed unequal  cicatrix,  having,  in  some  places,  a  thick  dark  co- 
loured scab  covering  it.*  The  neighbouring  glands  become 
affected  ;  but  they  are  soft,  and  rather  resemble  the  spon- 
goid  inflammation  than  schirrous  hardness :  But  I  have  never 
had  an  opportunity  of  observing  them  proceed  the  length  of 
ulceration.  If  the  continuance  of  the  sore  be  long,  the  con- 
stitution is  affected,  and  the  patient  becomes  hectic. f  This 
kind  of  ulcer  may  be  distinguished  from  cancer,  if  we  attend 
1o  the  absence  of  the  fungous,  and  peculiar  appearance  of 
I  he  cancerous  sore,  and  the  want  of  the  burning  pain  :  But, 
before  ulceration  takes  place,  the  two  diseases  may  be  con- 
founded ;  because  there  are  no  certain  characteristics  of 
schirro-cancer. 

This  disease  may  attack  the  uterus,  and  is  very  apt  to  be 
confounded  with  cancer;  nor  is  it  easy  to  distinguish  them, 
as  the  parts  are  unseen.  There  is  never  much  enlargement. 
The  ulcer  is  pretty  smooth,  and  the  margins  circular,  hard, 
and  glabrous.    The  pain  is  not  very  considerable.    The  dis- 


*  Of  this  nature  was  probably  the  ulcer  mentioned  by  Mr.  Wiseman,  at  least  if 
•ve  may  judge  from  his  very  short  description  :  "  It  hnd  eat  deep  into  her  left 
breast,  and  was  fixed  to  the  ribs,  but  not  with  much  pain.  In  progress  of  lime,  the 
lips  inverted,  and  united,  as  it  were,  and  lay  covered  with  a  crusty  scab;  the  hu- 
mour in  the  mean  while  spent  itself  upon  the  nerves,  iVc.  She  lived  long,  and,  in 
her  latter  age,  tolerably  healthful."     Chirurg.  Treatises,  vol.  i.  p.  165. 

t  Extirpation  is  the  only  certain  cure  of  this  disease  ;  and  it  is  at  all  times  1 1: r 
quickest  and  the  best;  but,  by  eschoritics,  we  may  sometimes  procure  cicatii  v 
tion,  at  least  if  the  gland  have  shrunk,  and  most  of  its  substance  been  destroyed. 


134 

charge  is  thin,  copious,  and  of  a  yellowish  colour,  but  seldom 
blood}',  unless  when  the  disease  has  continued  very  long. 

The  spongoid  inflammation  has  been  considered  as  cance- 
rous by  those  who  have  seen  it ;  but  the  distinction  betwixt 
the  two  is  sufficiently  obvious  :  The  one  begins  with  a  spongy 
elastic  tumour,  the  other  with  a  firm  hard  lump. 

Scrophula  may  be  mistaken  for  cancer,  when  it  appears 
in  one  of  the  secretory  glands,  such  as  the  breasts;  at  least 
as  long  as  it  remains  without  ulceration.  But  the  tumour 
generally  enlarges  more  rapidly  than  cancerous  tumours,  at 
least  such  as  are  not  very  painful.  It  is  pretty  soft  and 
doughy,  the  pain  is  inconsiderable,  and  we  may  generally 
perceive  the  marks  of  a  scrophulous  habit.  When  ulcera- 
tion takes  place,  the  opening  is,  for  some  time,  sinous,  and 
the  matter  discharged  is  curdy,  and  without  fcetor.  When 
the  ulceration  extends  along  the  skin,  it  has  not  the  fungous 
appearance  of  cancer,  but  the  aspect  of  a  scrophulous  sore, 
and  the  gland  below  appears  sloughy.  The  pain  is  not  very 
considerable,  and  is  not  of  the  burning  kind. 

Scrophulous  inflammation  may  also  attack  the  uterus, 
bladder,  and  any  of  the  internal  organs.  The  uterus  and 
bladder  become  thickened,  and  contain  abscesses  in  differ- 
ent parts,  which  point  on  the  surface  of  these  viscera.  They 
are  filled  with  a  thick  Avhite  cheesy-looking  matter  ;  and 
when  they  burst,  they  produce  ulcers,  with  a  foul  surface, 
and  having  the  margins  notched,  and  lying  for  a  considerable 
way  over  the  disk  of  the  sore. 

The  distinction  betwixt  cancer  and  the  venereal  ulcer  is 
so  very  striking,  that  it  is  scarcely  possible  for  these  dis- 
eases to  be  mistaken  for  each  other,  if  the  discriminating 
marks  of  each  be  attended  to.  The  cancerous  sore  is  al- 
ways dark  coloured  ;  the  surface  fiery,  yet  of  a  fungous  na- 
ture ;  the  discharge  foul,  and  of  an  intolerable  smell ;  and 
the  bottom  and  surrounding  parts  are  hard  and  painful.     If 


1X5 

there  be  not  an  open  running  sore,  the  part  is  covered  with 
a  dry  elevated  scab,  of  a  dark  colour ;  the  skin  around  this 
is  livid,  and  the  neighbouring  parts  indurated.  The  base  of 
Ihe  venereal  sore  is  much  softer,  the  discharge  is  of  a  differ- 
ent nature,  and  its  aspect-so  peculiarly  unlike  the  cancerous 
sore,  that  it  is  impossible  to  confound  them.* 

There  is  another  disease,  which  is  very  apt  to  be  con- 
founded with  cancer,  and  which,  at  one  period,  resembles  it 
very  much.  It  begins  with  a  small  tumour,  like  a  phleg- 
mon, of  a  dull  colour,  and  without  much  pain.  This  soon 
assumes  a  soft  elastic  feel,  and  bursts  at  the  top ;  a  blood  v 
rnatter  oozes  out,  the  lips  of  the  orifice  become  tumid,  and 
the  integuments  ulcerate.  The  whole  has  a  convex  surface, 
the  ulcerated  part  being  most  prominent ;  and  the  sloping 
margins  are  red  and  painful :  The  ulcer  itself  is  foul,  of  a 
dark  fungous  appearance,  and  covered  with  thick  offensive 
matter,  with  sloughs  in  different  parts  ;  the  margins  are 
hard,  and  lie,  in  a  serrated  manner,  over  part  of  the  sore  : 
The  pain  is  smarting.  This  sometimes  spreads  to  a  consi- 
derable extent,  and  cuts  off  the  patient.  At  other  times., 
by  the  use  of  mild  dressings,  good  diet,  and  opium  inter- 
nally, the  fungous  surface  sloughs  off  by  degrees,  and  shows 
a  smooth  red  bottom,  somewhat  striated,  and  of  a  glossy  ap- 
pearance, which  contracts,  and  scabs  over,  like  the  pseudo- 


*  It  is  to  be  regretted,  that  some  who  belong  to  our  profession,  reason  upon  the 
nature  of  ulcers,  not  from  appearances  anil  characteristic  marks,  but  from  the  pa- 
tient's manner  of  life,  or  the  idea  which  t'ney  have  formed  of  the  country  whence 
they  coma.  I  remember  two  instances  of  people  who  came  from  the  Hebrides,  the 
one  with  \  cancer  of  the  lip,  the  other  with  a  cancerous  nicer  on  the  neck,  both 
fungous,  and  possessing  the  burniog  pain,  and  every  character  of  cancer;  but  as 
the  sibbens  unluckily  prevailed  in  that  country,  it  was  thought  that  the  patient* 
might  have  received  this  infection,  and  accordingly  were,  by  a  full  consultation  of 
aurgeons,  condemned  to  undergo  a  course  of  mercury.  The  lip  was,  jo  three  day*, 
greatly  worse;  the  mercury  was  omitted,  and  the  patient  cured  by  an  operation-. 
The  sore  on  the  neck  was  instantly  exa«perated,  and  the  patient]  to  u<e  thi 
t»f  Hildantis,  "  had  her  soul  speedily  sent  to  heaven." 


186 

cancer.  The  fungous,  in  this  ulcer,  never  rises  high  ;  it  is 
generally  slightly  convex,  being  most  prominent  at  the  cen- 
tre, and  has  never  the  retorted  trumpet-like  appearance  of 
some  cancers. 

Phagedena  has  sometimes,  particularly  on  the  yard,  been 
confounded  with  the  cancerous  sore.  It  has  indeed  the 
brown  fiery  colour,  and  smarting  pain,  possessed  by  the  can- 
cerous ulcer ;  but  it  wants  the  fungous  appearance,  which 
the  cancer  very  soon  assumes.  It  spreads  with  greater  ra- 
pidity, and  is  not  surrounded  by  the  same  hardness.  It  be- 
gins likewise  more  suddenly,  and  without  any  previous  hard 
tumour.  We  frequently  hear  of  venereal  buboes  becoming 
cancerous  ;  but  this  seldom,  if  ever,  happens  ;  and  phagedena 
has,  iu  this  case,  been  confounded  with  cancer  ;  for  that 
spreading  fiery  honey-comb-like  ulcer,  which  venereal  bu- 
boes sometimes  turn  into,  is  evidently  of  the  phagedenic 
nature. 

It  was  from  allowing  too  great  latitude  to  the  description 
or  definition  of  cancer,  as  well  as  from  the  numerous  divi- 
sions admitted  by  the  older  writers,  such  as  mild,  raging, 
and  the  like,  that  many  diseases  have  come  to  be  considered 
as  cancerous,  which  are  in  their  nature  perhaps  radically 
different  from  it. 

The  mild  cancer  was  said  to  begin  slowly,  with  little  pain, 
to  continue  long  indolent,  and  to  ulcerate  slowly :  The  ul- 
cer was  not  very  painful,  and  frequently  healed  with  a  scab, 
or  remained  long  stationary.  This  evidently  was  not  a  can- 
cerous disease,  but  the  one  which  I  have  described  above. 
On  cutting  into  this  tumour,  after  extirpation,  we  find  it  to 
be  of  a  firm  texture,  the  interstices  filled  with  a  kind  of 
oily  matter,  and  no  cavities  with  thickened  sides  in  its  sub- 
glance. 

The  malignant,  or  true  cancer,  begins  with  a  hard  schir- 
rous  tumour,  with  frequent  lancinating  pain  ;  the  skin  soon 


187 

adheres  to  the  gland,  and  becomes  slightly  puckered,  and  of 
a  livid  or  leaden  colour ;  the  veins  are  more  or  less  varicose, 
although  the  tumour  be  not  large  ;  and  the  nipple,  when  the 
disease  is  in  the  breast,  is  generally  drawn  inward.  The  in- 
teguments next  become  red,  and  a  small  opening  forms, 
through  which  is  discharged  a  bloody  serous-looking  matter, 
generally  in  very  considerable  quantities.  The  ulcer  which 
succeeds  this  is,  at  first,  superficial,  affecting  only  that  part 
of  the  integuments  which  covered  the  pointing  of  the  glandu- 
lar cyst  or  abscess.  It  is  dark  coloured  and  fiery,  like  pha- 
gedena ;  but  the  edges  are  hard  and  ragged,  and  overlap  ir- 
regularly, in  different  spots,  small  parts  of  the  surface  of  the 
sore.  In  the  course,  however,  of  a  few  days,  sometimes  in  a 
few  hours,  a  fungus  protrudes,  and  increases  more  or  less  rapid- 
ly, at  the  same  time  that  the  sore  spreads  laterally.  This 
fungus  is  very  irregular,  of  a  dark  colour,  and  covered  with 
sloughy-looking  pellicles.  It  generally  sprouts  out  most  to- 
ward the  circumference,  so  that  the  sore  has  often  the  ap- 
pearance of  the  mouth  of  a  trumpet ;  or  if  the  cavity  in  the 
middle  be  less,  the  fungus  being  less  turned  out,  it  resembles 
a  cauliflower.  This  fungus  uniformly  projects  over  the 
margins,  which  are  hard  and  red.  The  matter  discharged 
is  thin,  bloody,  and  exceedingly  foetid.  On  examining  these 
glands,  we  find  them,  in  the  commencement,  to  be  hard,  like 
a  substance  intermediate  betwixt  gland  and  cartilage,  and  of 
an  indistinct  granulated  structure.  Soon  afterwards,  we  per- 
ceive small  abscesses  or  cavities  in  different  parts,  which 
are  filled  with  a  serous  fluid,  and  the  sides  of  which  are  hard 
and  firm,  like  gristle.  These  enlarge  gradually,  and  new 
ones  form ;  so  that  were  we  to  cut  the  gland,  we  should  find 
it  containing  a  great  number  of  these   cavities.*     Those 

*  These  are  sometimes  very  irregular  in  their  shape,  and  have  their  sides  very 
thin ;  so  that,  at  first  sight,  they  appear  like  cavities  formed  by  the  separation  of 
he  fibres  of  the  part. 

VOL.   II.  A    2 


]88 

which  are  nearest  the  surface  of  the  gland,  generally  enlarge 
most ;  and  sometimes  only  one  gains  any  considerable  size. 
Before  this  bursts,  its  sides  become  more  opake,  and  more 
blended  with  the  rest  of  the  gland,  (which,  where  it  sur- 
rounds the  abscess,  becomes  softer,  rather  more  vascular, 
and  more  porous  or  spongy  than  in  other  parts,  and  than  it 
formerly  was,)  unless  it  distend  beyond  the  substance  of 
the  gland,  pushing  the  skin  outward.  In  this  case,  when  it 
bursts,  a  great  quantity  of  lymphatic  matter  is  discharged, 
and  the  part  collapses,  and  then  exhibits  the  usual  appear- 
ances of  the  cancerous  ulceration  :  But,  more  frequently,  we 
find  the  abscess  remain  altogether  in  the  gland,  and  only  dis- 
tend the  skin  a  little  at  the  apex,  where  it  points.  When  the 
abscess  bursts,  more  or  less  fluid  is  discharged,  and  immedi- 
ately the  inner  surface  begins,  like  the  orifice,  to  ulcerate. 
A  fungus  is  produced  from  the  sides  of  the  abscess,  which 
fills  up  the  cavity,  and  then  protrudes  from  the  orifice.  We, 
therefore,  find,  that  when  the  cancerous  abscess  bursts,  the 
orifice  at  first  assumes  the  appearance  of  a  cancer  which  be- 
gins in  the  cutis  j*  but  very  soon  a  fungus  protrudes,  and  the 
ulcer  gradually  becomes  more  convex,  or  more  like  a  cauli- 
flower. 

These  abscesses,  with  thick  sides,  are  characteristic  of 
cancer,  and  are  never  found  wanting  in  a  cancerous  gland. 
When  they  are  not  present,  we  may  be  certain,  that  the  tu- 
mour is  a  difierent  kind  of  schirrus.  But  although  these  be 
always  found  in  the  glands,  and  form  in  them  a  certain  mark 
of  cancer,  yet  they  are  not  necessary  to  the  existence  of  that 
disease ;  for  the  cancerous  ulcer,  like  common  ulcers,  may 


*  That  is  to  say,  the  sore  is  rather  flabby  than  fungous ;  for  cancerous  ulcers 
which  begin  superficially,  and  without  previous  abscess,  remain  a  considerable 
time  without  forming  fungus;  but  when  an  abscess  bursts,  and  the  skin  ulcerates 
inconsequence,  then  the  sore  is  not  superficial,  but  communicates  with  the  ab- 
scess, which  forms  fungus  quickly. 


189 

begin  without  previous  abscess,  as  we  observe  in  the  cancer 
of  the  skin,  which,  in  nine  cases  out  of  ten,  begins  with  ex- 
crescences like  warts. 

By  attending  to  these  circumstances,  we  may  generally 
form  a  pretty  just  diagnosis.  At  the  same  time,  it  must  be 
admitted,  that,  occasionally,  cases  do  occur,  in  which  it  is 
impossible  to  deliver  a  decided  opinion  :  Nor  is  it  doubtful, 
that  many  ulcers  are  considered  as  cancerous,  which  are  of 
a  different  nature,  and  some  of  which  admit  of  a  cure.  In 
forming  our  judgment,  we  must  be  directed  by  the  nature  of 
the  first  symptoms,  and  the  history  of  the  schirrous  stage  ^ 
by  the  appearance  and  aspect  of  the  fungus,  and  the  other 
circumstances  which  have  been  already  described. 

Concerning  the  peculiar  state  of  the  parts  in  cancer,  or  the 
proximate  cause,  many  opinions  have  prevailed ;  but  these, 
however  they  might  differ  in  certain  points,  have  almost 
unanimously  agreed  in  admitting  obstruction  as  the  chief 
cause  of  this  disease. 

Until  lately,  the  melancholic  humour  was  supposed  to  be 
the  fluid  which  was  obstructed,  and  accumulated,  in  conse- 
quence of  which  it  fermented,  and  produced  a  burning  ulcer ; 
and  whatever  promoted  the  generation  of  this  humour,  was 
currently  admitted  as  a  remote  cause  of  cancer.  Women, 
says  Ambrose  Pari',  are  more  subject  to  schirrus  than  men ; 
"  because  their  liver  is  warmer,  and  their  spleen  being  weak- 
er, is  less  able  to  purge  the  blood  of  choler."  Grief  and  cha- 
grin, by  promoting  the  formation  of  this  fiery  fluid,  were  ac- 
cordingly considered  by  the  celebrated  Heister,  as  very  apt 
to  induce  the  "  cancerous  diathesis  ;"  and  he  slyly  adds,  by 
way  of  corollary,  that  "  old  maids,  and  women  who  do  not 
breed,  are  very  subject  to  cancer  in  the  breast."* 

*  Heister's  Iostitut.  Vol.  I.  p.  229, 


190 

Concerning  the  particular  changes  which  took  place  its 
(he  nature  of  this  obstructed  humour,  many  different  opi- 
nions prevailed.  Some  thought  it  necessary,  that  the  black 
bile  should  be  charged  with  an  acid,  and  that  this  produced 
ulceration,  when  "  its  sharp  cutting  points  had  surmounted 
and  destroyed  the  volatile  smegmatic  and  balsamic  salts  of 
the  blood."  Others  conjectured,  that  by  an  "  adustion  or 
over-concoction,"  it  grew  sharp  and  burning :  But  Wiseman 
observes,  that  it  is  more  probable  that  it  becomes  somewhat 
arsenical.  It  would,  however,  be  useless  to  enumerate  the 
different  changes  which  this  imaginary  humour  was  supposed 
to  undergo*  It  is  sufficient  to  observe,  that  these  were  al- 
most universally  believed  to  depend  upon  the  previous  stag- 
nation, in  consequence  of  obstruction  ;  and  this  leading  point 
has  uniformly  been  insisted  on  by  every  succeeding  authorr 
whatever  might  have  been  his  particular  notion  with  regard 
to  the  nature  of  the  obstructed  fluid,  whether  bile,  blood,  or 
lymph;  and  even  Ihe  anatomical  structure  of  the  part  has 
been  brought  in  support  of  the  doctrine  of  obstruction.  One 
of  the  latest  writers,*1  though  he  talks  nothing  of  "  coagula- 
ting acids,"f  yet  insists  fully  on  this  mechanical  cause  as 
the  origin  of  cancer;  "  for,"  says  he,  "  the  circulation  in  the 
glands  being  carried  on  by  a  set  of  vessels  much  more  minute 
than  those  with  which  other  parts  of  the  body  are  supplied, 
(let  this  be  proved,)  obstruction  will  much  more  readily  and 
easily  occur  in  them  than  in  other  parts." — "  When  the 
substance  of  a  gland  happens  to  be  the  part,  a  determination 
is  made  to  this,  being  neither,  as  is  found  by  experience, 
so  proper  as  the  cellular  substance,  for  the  formation  of  pus, 
nor,  from  its  softness,J  so  susceptible  of  inflammation,  as  a 
membrane ;  an  indolent  hard  swelling,  called  a  schirrus,  comes, 

*  Bell  on  Ulcers,  p.  3ia 

f  Dioni's  Cliir.  p.  2-48. 

t  Does  inflammation  depend  upon  the  hardness  or  softness  of  the  inflamed  part? 


191 

merely  by  the  obstruction  and  distension*  of  its  different 
vessels,  very  naturally  to  be  produced." 

Some  surgeons,  perhaps  from  a  desire  of  singularity,  or 
from  a  defect  of  their  organs  of  sight,  declared,  that  they 
had  detected  little  worms  in  the  parts,  which,  eating  it  up, 
produced  all  the  disagreeable  symptoms  of  cancer ;  and  that 
to  their  introduction  the  disease  was  owning.  The  cure 
which  they  confidently  proposed,  was  applying  a  piece  of 
cold  veal  to  the  part,  which  would  tempt  the  animals  to  quit 
their  devastation.  Others,  perhaps  originally  from  ridicule, 
though  latterly  in  sober  earnest,  told  their  readers,  that 
there  were  no  worms,  but  a  little  wolf  in  the  part,  which 
might  be  made  occasionally  to  show  its  head,  by  holding  a 
piece  of  meat  before  the  ulcer. 

Strange  as  this  doctrine  of  living  creatures  producing 
cancer  may  appear,  it  is  nevertheless  adopted  by  a  late 
very  ingenious  writer.  When  hydatids  find  their  way  into 
"  a  solid  substance,"  the  consequence,  in  his  opinion,  will  be 
cancer ;  and  the  success  of  an  operation  will,  he  conjectures, 
depend,  in  a  great  measure,  upon  these  animals  being  con- 
fined in  a  common  cyst,  for  then  they  may  be  all  removed ; 
whereas,  if  they  be  unconnected,  some  of  the  smaller  ones 
may  be  allowed  to  remain. f  From  the  surface  of  the  cyst, 
which  contains  the  animal,  a  fungus  shoots  out,  and  thus  acts 
as  a  barrier  between  it  and  the  skin ;  or,  if  the  animal  have 
been  in  the  stomach,  it  separates  it  from  the  coats  of  that 
viscus,  "  preventing  suppuration  in  the  one  instance,  and  ab- 
sorption in  the  other.":}:     This  suppuration,  "and  disposition 

*  One  should  expect,  that  the  distension  of  the  vessels  would  diminish  the  cause 
of  obstruction,  or  remove  it  altogether. 

It  is  rather  unlucky,  that  the  advocates  for  obstruction  have  made  it  the  cause 
of  simple  inflammation,  scrophula,  cancer,  &c. ;  and  therefore  all  these  diseases 
ought  to  be  nearly,  if  not  entirely,  similar  in  their  nature,  and  to  require  exactly 
the  same  means  of  cure. 

t  Adam's  Observations  on  Morbid  Persons,  p.  184. 

t  Idem,  p.  185. 


192 

to  fungate  before  the  skin  is  broken,"  if  I  understand  him,  is 
produced  by  the  death  of  the  animal ;  for,  says  he,  "  if  hy- 
datids possess  the  principle  of  vitality  during  their  transpa- 
rent state,  and  their  opacity  is  the  effect  of  the  loss  of  that 
principle,  would  they  not,  in  the  latter  stage,  stimulate  the 
part  in  which  they  are  situated  to  suppuration,  as  we  find 
the  case  with  the  Guinea  worm  when  dead?"*  Concerning 
the  manner  in  which  these  animals  produce  the  symptoms  of 
cancer,  we  are  told,  that  "  this  enlargement  of  a  foreign  body, 
in  a  solid  substance,  and  so  extremely  sensible  as  the  breast, 
cannot  but  be  attended  with  intense  pain,  and  frequent  in- 
flammation."! A  doctrine  not  far  removed  from  that  taught 
in  the  humoural  schools,  which  maintained,  that  the  coagula- 
tion and  inspissation  of  the  fluids  distended  the  follicles  of 
the  glands,  producing  many  cavities,  and  much  pain. J 

That  hydatids  may  be  formed  on  a  cancerous  gland,  I 
shall  not  dispute  ;  but  that  they  are  generally  to  be  met 
with,  or  are  in  any  respect  essential  to  the  disease,  I  can- 
not admit.  In  all  the  cancerous  breasts,  testicles,  and  tu- 
mours, which  I  have  examined,  I  never  saw  any  thing  which 
could  be  considered  distinctly  as  a  hydatid ;  so  that  I  sus- 
pect, that  under  this  name  have  been  described  the  small 
cancerous  abscesses,  with  thick  cartilaginous  sides,  which 
we  so  universally  meet  with  in  schirro-cancerous  glands. 
We  likewise  find  cancer  take  place  in  circumstances  in' 
which  no  hydatids  can  be  found.  Thus,  for  instance,  a  can- 
cerous wart  being  knocked  off  the  face,  a  cancerous  ulcer  is 
produced ;  but  no  hydatid  is  to  be  found  at  the  base  of  the 
wart  to  produce  this. 

When  cancer  has  continued  some  time,  it  was  believed 
that  the  matter  was  absorbed,  taken  into  the  blood,  and  that 

*  Adam's  Observations  on  Morbid  Persons,  p.  184. 

f  Idem.  p.  161. 

t  Van  Swieten's  Commentaries,  article  Cancer. 


193 

all  the  humours  were  speedily  assimilated ;  and  it  was  by  this 
absorption  and  assimilation  that  they  explained  the  fatal  and 
rapid  progress  of  relapses,  after  an  apparent  cure  had  been 
obtained.  That  matter  is  absorbed,  is  an  undeniable  fact : 
but  the  only  effect  which  is  produced  by  this,  is  on  the  lym- 
phatic glands,*  which  intervene  betwixt  the  sore  and  the 
heart ;  for,  beyond  these,  the  matter  does  not  pass  qua  virus, 
but  is  changed  in  its  nature  and  properties,  as  is  the  case 
with  every  other  part  or  production  of  the  animal,  which  is 
absorbed  and  formed  into  part  of  the  blood.  Neither  can- 
cerous matter,  nor  variolous  matter,  nor  syphilitic  matter, 
ever  are  formed  in  the  blood,  or  ever  can  enter  into  it,  un- 
less by  means  of  a  wounded  vessel.  This  point  I  shall  con- 
sider more  fully,  when  I  come  to  treat  of  the  venereal  inflam- 
mation. Here  I  shall  only  observe,  that  were  the  reverse 
true,  then  the  contagious  matter  must  pass  through  every 
gland,  and  every  portion  of  the  human  form,  in  as  much  as 
the  blood  circulates  in  every  point ;  and,  therefore,  every 
spot  should  become  diseased,  and  every  part,  in  the  same 
circumstances,  should  become  diseased  at  the  same  moment.f 
Disease  is  not  spread  in  the  living  system  mechanically,  by 
the  absorption  of  matter,  which  is  conveyed  over  the  whole 
body,  but  by  the  sympathetic  connexion  of  parts,  which  has 

*  Mr.  Hunter  supposes,  that  the  mere  absorption  of  schirrous  substance  before 
matter  be  formed,  will  affect  the  glands;  but  it  is  difficult  to  ascertain  the  certain- 
ty of  this,  as  small  abscesses  are  formed  very  early.  I  have  formerly  mentioned, 
that  every  part  of  the  animal  is  changed  in  its  nature,  at  the  moment  of  being  ab- 
sorbed: If  so,  schirrous  substances  lose  all  specific  property,  and  cannot  affect  the 
glands.  Pus,  again,  being  a  foreign  matter,  is  absorbed  unchanged,  and  continues 
so  until  it  reaches  the  glands. 

f  It  may  be  said,  that  different  parts  have  different  susceptibilities  of  assuming 
the  morbid  condition  ;  that  the  bones  are  longer  of  becoming  affected  than  the  soft 
parts,  &c.  Admit  this,  and  still  it  must  be  explained,  why  every  part  of  a  similar 
structure,  &c.  should  not  be  affected  at  the  same  moment.  All  the  glands  should 
become  diseased  at  once;  all  the  bones  should  inflame  at  the  same  time;  and,  in- 
stead of  finding  one  or  two  organs  affected,  in  consequence  of  the  previous  existence 
of  a  local  disease,  we  should  find  the  whole  system  rapidly  becoming  diseased.    ^ 


194 

tjeen  already  explained,  and  which  will  afterwards  be  farther 
illustrated.  It  is  in  consequence  of  this,  that  a  distant  part 
shall  become  diseased,  and  yet  all  the  rest  remain  healthy ; 
and  even  where  every  part  becomes  affected,  and  a  general 
disease  is  suddenly  produced  from  a  local  sore,  as,  for  in- 
stance, in  small-pox,  there  is  no  diffusion  of  matter,  nor  is  it 
ever  conveyed  beyond  the  lymphatic  glands. 

In  this  particular  complaint,  the  consequence  of  sympa- 
thetic action,  or  the  propagation  of  action,  is  sometimes  the  in- 
duction of  the  same  disease  in  other  parts ;  but  most  common- 
ly the  effect  is  the  establishment  of  the  hectic,  or  diseased 
formative  action ;  for  an  explanation  of  which  I  refer  to  the 
dissertation  on  simple  inflammation. 

By  examination,  we  find,  that,  in  many  instances,  cancer 
is  evidently  produced  by  the  same  causes  which  are  capa- 
ble of  producing  simple  inflammation ;  and,  in  every  instance, 
I  apprehend,  that  although  the  causes  may  be  obscure,  yet 
they  are  exactly  of  the  same  nature.  It  is,  however,  a  ge- 
neral opinion,  that  this  disease  arises  frequently  from  some 
unknown  and  mysterious  cause  which  we  cannot  detect,  and 
which,  therefore,  has  been  resolved  into  some  constitutional 
taint,  or  cancerous  ferment.  But,  so  far  as  we  know,  the 
constitution  is  perfectly  healthy  in  the  commencement  of 
this  disease  ;  nor  is  there  the  smallest  proof  that  it  resem- 
bles scrophula,  in  depending  upon  any  peculiarity  of  consti- 
tution, before  the  causes  operate. 

Blows,  bruises,  and  other  exciting  causes  of  inflammation, 
are  apt  to  produce  cancer  ;  but,  in  many  instances,  we  can 
detect  no  evident  local  cause  acting  directly  on  the  part. 
In  the  breast,  for  instance,  we  frequently  perceive  cancer 
commence  without  the  interference  of  any  topical  agent.  In 
these  cases,  however,  we  may  uniformly  detect  an  irregu- 
larity or  disappearance  of  the  menstrual  secretion.  It  was 
rormerly  observed,  that  the  uterus  and  mammae  exhibited 


195 

very  powerfully  the  sympathy  of  equilibrium ;  and  it  is  upon 
this  doctrine,  which  it  is  unnecessary  farther  to  illustrate, 
that  we  are  to  explain  the  affection  of  the  breast,  which  so 
frequently  takes  place  in  consequence  of  the  cessation  of 
the  menses ;  for  when  the  active  state  of  the  uterus  is  los.t, 
the  action  of  the  mammae  is  preternaturally  increased,  and  a 
species  of  slow  inflammation  is  induced.  It  is  upon  this 
principle  only  that  we  can  explain  why  cancers  are  so  fre- 
quent at  the  cessation  of  the  menses.*  It  is  ridiculous  to 
suppose  that  this  discharge  acts  as  a  drain  to  the  constitu- 
tion, and  carries  off  impurities,  which  would  otherwise  col- 
lect elsewhere,  and  produce  local  diseases.  The  breast  is  al- 
most the  only  organ  which  becomes  thus  affected  without 
any  agent  acting  directly  upon  the  part  alone  ;  for,  inmost 
other  instances,  we  may  detect  the  operation  of  such  causes 
at  least  as  tend  to  induce  simple  affections  of  the  same  part ; 
but,  in  both  instances,  the  modus  operandi  of  the  cause  is 
alike,  only  circumstances  are  somewhat  varied. 

When  the  inflammatory  action  is  slowly  induced,  whether 
by  a  bruise,  or  any  other  cause,  acting  directly  on  the  part, 
or  by  sympathetic  union  with  another  part,  we  find,  that  the 
tumour  which  is  consequent  to  this,  seldom  manifests  a  dispo= 
sition  to  remove  quickly,  or  assume  the  healing  process. 
The  part  neither  performs  airy  distinct  and  acute  inflamma- 
tory action,  nor  does  it  resume  its  natural  condition  and  ap- 
pearance, but  remains  in  a  new  state,  different  from  either, 
which  I  will  call  the  state  of  simple  schirrus.f     If  this  state, 

*  It  was  supposed,  that  wheu  the  menses  were  obstructed,  the  impurities  were 
sent  by  communicating  vessels  to  the  breast,  where  they  lodged,  and  produced 
cancer.    Vide,  Vesalii  Opera,  p.  1092.    Fabricius  de  Turn.  p.  118. 

Le  Dran  observes,  that  when  schii  rus,  from  any  cause,  takes  place  in  the  breast, 
before  the  cessation  of  the  meuses,  it  uniformly  becomes  more  painful  when  any 
irregularity  of  that  discharge  occurs.  Vide,  Memoires  de  l'Acad.  de  Chirurg, 
torn.  iii.  p.  22. 

f  Warts  <\re,  with  regard  to  their  power  of  acting,  to  be  considered  in  the  sattfe 
'ight  with  simple  schrtrt 

vol.  rr.  2  u 


196 

which  may  follow  the  application  of  the  common  exciting 
causes  of  inflammation  in  any  part,  take  place  in  cellular  sub- 
stance, or  similar  parts,  which  are  possessed  of  no  glandu- 
lar structure,  then  a  chronic  tumour  is  produced,  which  is 
either  slowly  diminished  by  absorption,  or  at  last  unable  to 
carry  on  its  actions  in  perfection,  being,  in  some  respect,  in- 
sulated, and  deprived  of   the   support  of  the  surrounding 
parts  ;*  a  diseased  action,  or  morbid  performance  of  its  ac- 
tions, takes  place  ;    a  slow  inflammatory  condition  is  pro- 
duced,! and  a*  last  ulceration  succeeds.     This,  in  general, 
forms  pseudo-cancer,  provided  that  the  constitution  be  sim- 
ple, that  is  to  say,  healthy  :  But  if  it  take  place  in  a  scro- 
phulous  habit,  the  tumour  is  apt  to  become  scrophulous, 
having  its  morbid  actions  modified  by  the  morbid  condition 
of  the   system.     If  this  event  take  place   in  a  lymphatic 
gland,  instead  of  the  cellular  substance,  then  the  tumour  is 
still  more  apt  to  become  affected  with  scrophulous  inflam- 
mation, in  consequence  of  even  a  very  trifling  scrophulous 
modification  of  the  habit.     If  this  state  be  produced  in  a 
secretory  gland,  the  affection  is  somewhat  different  from  that 
in  simple  parts,  or  those  which  do  not  secrete  ;  because  the 
inflammatory  action  becomes  somewhat  modified  by  the  na- 
tural secreting  action  of  the  part ;  and,  in  this  point  of  view, 
the  gland  may  be  considered  as  possessing  a  specific  consti- 
tution, although  the  general  constitution  be  simple ;  for,  na- 
turally possessing  a  peculiar  mode  of  action,  it  follows,  that 
new  actions  induced  iu  such  a  part,  ought  to  be  performed 
in  a  different  manner  from  the  same  actions  in  parts  which 
naturally  do  not  possess  this  peculiarity,  and  that  the  actions 
ought  to  be  specifically  different.     When  these  parts  are  at- 


*  See  the  Note  to  p.  ]  54. 

t  The  simple  schirrua  now  assumes  that  specific  mode  of  inflammatory  action 
which  ii  is  to  continue,  and  may  now  be  called  the  scrophulous  or  cancerous  in- 
Tamed  schirma. 


197 

tacked  with  acute  simple  inflammation,  it  differs  from  in- 
flammation in  the  cellular  substance  in  certain  circumstances, 
and  particularly  in  being  much  more  tedious ;  but  when  the 
nature  of  the  part  is  still  farther  altered  by  the  accession  of 
a  slow  inflammatory  action,  which  operates  in  the  manner 
above  described,  then  it  assumes  a  specific  inflammation, 
which  ends  in  ulceration.  The  exact,  or  specific  nature  of 
this,  is  various  ;  and  the  state,  which  we  call  cancerous,  is 
probably  only  one  of  the  varieties  of  this  morbid  inflamma- 
tory action ;  and  whether  the  part  shall  assume  this  variety, 
or  some  other  variation,  as,  for  instance,  pseudo-cancer,  de- 
pends probably  upon  local  circumstances,  which  we  cannot 
as  yet  detect  or  explain.  If,  however,  the  constitution  pos- 
sess any  specific  mode  of  action,  the  tumour  generally  as- 
sumes nearly  the  same  mode  ;  and,  therefore,  in  scrophnlous 
people,  these  tumours  more  frequently  become  affected  with 
scrophulous  inflammation,  than  with  cancer:  At  the  same 
time,  if  the  previous  change  on  the  gland,  induced  by  the 
slow  inflammatory  condition,  have  been  great,  the  scrophu- 
lous condition,  which  it  possesses  in  common  with  the  rest 
of  the  system,  becomes  modified  in  it,  in  the  same  way  as 
the  simple  condition,  in  healthy  habits,  is  modified  by  the 
new  or  schirrous  state  of  the  gland  ;  and,  therefore,  the 
scrophulous  inflammation  is  sometimes  different,  and  the  ul- 
ceration more  fungous  than  in  other  parts. 

The  causes,  then,  of  simple  inflammation,  when  they  ope- 
rate slowly,  or  leave  the  part  in  a  state  neither  inflamed  nor 
healthy,  give  rise  to  a  chronic  enlargement,  and  change  of 
nature,  which  I  have   called  simple  schirrus.*     This  per- 

*  Schirrus  has  generally  been  enumerated  as  one  of  the  terminations  of  inflam- 
mation ;  but  it  cannot,  properly  speaking,  l>e  considered  as  such.  There  are  only 
two  kinds  of  termination,  one  in  death,  as,  for  instance,  gangrene  ;  tlie  other  in  re- 
covery, which  is  accomplished  either  directly  by  resolution,  or  indirectly  by  sup- 
puration.   Schirrus  is  not  produced  by  a  perfect  and  complete  cessation  of  inC.am 


193 

forms,  like  every  other  part,  certain  actions,  which  are  in- 
tended for  its  own  support,  and  which  must  make  a  part  of 
the  general  action  of  the  system,  or  be  in  unison  with  the 
rest  of  the  body.  But  as  its  actions  are  different  in  nature 
from  those  which  any  part  of  the  body  naturally  ought  to 
perform,  and  as  originally  this  organ,  (which,  from  the 
changes  induced  on  it,  is  to  be  considered  as  new  and  extra- 
neons,)  formed  no  part  of  the  human  frame,  there  is  not  that 
connexion  betwixt  it  and  the  rest  of  the  system,  which  is 
necessary  for  its  support.  It,  therefore,  does  not  derive  the 
same  aid  and  support  from  the  neighbouring  parts  which  na- 
tural organs  do,  (for  no  part,  or  individual  organ,  can  exist 
and  support  itself  singly,  and  independent  of  the  rest,)  and, 
accordingly,  must  soon  come  to  suffer.  It  is  unable  to  per- 
form its  necessary  actions  in  perfection  ;  they  become  mor- 
bid, and  of  an  inflammatory  nature.  The  tumour  is  now  an 
inflamed  schirrus  ;  and  this  inflammation  either  assumes  a 
modification,  from  the  specific  nature  of  the  constitution,  or 
from  the  peculiar  nature  of  the  tumour  itself,  which,  as  has 
been  explained,  is  different  from  the  healthy  state  of  the  tu- 
mid part.  We  have,  therefore,  the  scrophulous,  the  cancer- 
ous, the  pseudo-cancerous  inflamed  schirrus  ;  and  the  symp- 
toms of  these  different  kinds  of  schirri,  and  the  appearance 
of  the  ulceration,  will,  'caeteris  paribus,  be  modified  by  the 
nature  of  the  part  affected.  The  same  disease,  therefore, 
exhibits  slight  variations  in  different  organs,  as  has  been 
described  in  the  history  of  cancer,  and  might,  therefore,  were 
we  inclined  to  multiply  distinctions,  fee  considered  as  so  many 
different  diseases. 


mation,  but  by  a  continuance  of  a  low  degree  of  inflammation,  which  renders  the 
state  of  tumefaction  which  attends  it  natural  to  the  part,  before  it  goes  off.  This 
state,  then,  is  not  a  termination  of  inflammation,  but  a  consequence  of  its  continu- 
ance. 


199 

This  disease  is  most  apt  to  take  place  in  elderly  people, 
(in  so  much  that  some  consider  it  as  peculiar  to  old  age ;)  be- 
cause in  them,  parts  sustain  injury  of  their  actions  worst,  or 
are  less  able  to  recover  from  them.  Hence,  two  consequen- 
ces follow:  First,  Simple  schirrus  is  more  easily  produced, 
resolution  of  inflammation  being  more  difficult,  especially  in 
parts  which  are,  at  all  times,  rather  tedious  in  their  recovery, 
when  inflamed :  Second,  The  simple  schirrus  is  more  apt  to 
inflame,  or  have,  what  may  be  called,  its  necessary  actions 
impeded  and  deranged.  It  must,  however,  be  remembered, 
that  there  is  no  age  whatever  exempted  from  this  disease  :  I 
have  seen  it  distinctly  marked,  and  attended  with  a  fatal 
event,  in  children  of  five  years  old.* 

It  is  a  controverted  point,  how  far  it  is  possible  to  produce 
cancer  by  inoculation ;  some  maintaining,  that  the  applica- 
tion of  cancerous  matter  to  a  sound  part  will  induce  the  dis- 
ease ;  others,  that  rt  is  altogether  harmless.  Analogical 
evidence  is  certainly  in  favour  of  the  first  opinion  ;  because 
the  majority  of  specific  ulcers  may  be  inoculated,  and  have 
been  so  by  accident.  But,  at  the  same  time,  it  must  be  ad- 
mitted, that  there  are  few  well  established  cases  of  this  par- 
ticular point.  We  find,  however,  that,  like  the  venereal 
matter,  the  cancerous,  when  absorbed,  induces  a  disease  in 
the  lymphatic  glands,  of  a  cancerous  nature.  We  would, 
therefore,  be  led  to  conclude,  that  if  the  matter  be  capable 
of  inducing  cancer  by  absorption,  in  a  distant  part,  it  ought 
likewise  to  be  capable  of  producing  the  same  disease  in 
another  person  by  inoculation.  The  same  may  be  said  of  the 
spongoid  inflammation,  &c. 


*  I  have  known  two  cases  of  this  kind;  in  both  the  eye  was  affected.  One  boy 
had  his  eye  extirpated;  but  a  small  part  being  left  by  the  surgeon  at  the  angl^, 
the  disease  returned,  and  proved  fatal.  In  another,  the  disease  was  in  its  incipi 
cut  stage ;  hut  Urn  relations  would  not  submit  to  an  operation. 


200 

From  these  observations,  it  will,  I  presume,  appear,  first, 
That  when  a  pari  is  incapable  of  performing  the  actions  ne- 
cessary for  its  preservation  in  a  state  of  health,  it  generally 
slowly  assumes  the  inflammatory  state,  which  goes  on  to  ul- 
ceration ;  but  the  part  being  unable  to  support  its  natural 
action,  can  much  less  perform  the  actions  necessary  for  re- 
storation from  this  morbid  condition,  which,  therefore,  con- 
tinues permanently  and  progressively  increasing ;  that  the 
nature  of  this  unhealthy  action  is  not  always  the  same,  but 
admits  of  variations  dependent  upon  certain  conditions  in 
the  previous  state  of  the  part  affected,  with  regard  to  which 
we  are  greatly  in  the  dark.  Cancer,  pseudo-cancer,  spon- 
goid  inflammation,  &c.  are  some  of  these  variations. 

Secondly,  Cancer,  and  all  these  variations,  are  originally, 
in  the  strictest  sense  of  the  word,  local  diseases,  depending 
neither  upon  any  constitutional  affection,  nor  the  presence  of 
any  general  cause.  They  do,  however,  in  progress  of  time, 
affect  not  only  parts  in  their  vicinity,  but  also  the  system  in 
general,  producing,  by  means  of  sympathetic  actions,  speci- 
fic hectic  affections,  as  has  been  formerly  explained,  when 
treating  of  simple  hectic.  They  likewise  spread  over  more 
surface  in  the  part  at  first  affected,  and  produce  the  same 
morbid  actions  without  variation,  by  means  of  the  sympathia 
consociationis  serpens.  They  also  induce  a  similar  disease 
in  the  nearest  lymphatic  glands,  by  absorption. 

Of  tut  Prevention  and  Treatment  of  Cancer. 

Prom  what  has  been  said,  it  will  appear,  that  cancer  is  to 
be  prevented  by  using  the  most  vigorous  means  for  the  re- 
moval of  simple  schirri,  upon  their  first  appearance.  Of 
these,  local  bleeding  is  the  most  powerful,  and  ought  to  be 
freely  employed.  Next  to  this,  an  issue  in  the  neighbour- 
hood of  the  part  ought  to  be  most  depended  on ;  and  these 


201 

two  remedies  must  be  employed  early,  and  continued  care- 
fully.    Whenever  a  simple  schirrus  arises,  we  ought  to  be 
on  our  guard,   in  whatever  situation  it  may  be  placed  ;  but, 
if  it  occupy  a  secretory  gland,  we  require  to  be  doubly  vi- 
gilant.    This,  at  first,  is  not  painful,  at  least  the  patient  only 
complains  of  slight  uneasiness  shooting  for  a  moment  through 
it.     This  circumstance  too  frequently  prevents  the  patient 
from  attending  to  it;  for  where  there  is  no  inconvenience 
sustained,  there  is  little  inducement  to  apply  for  assistance ; 
and,  not  unfrequently,  an  ill-judged  modesty  contributes  to 
this  delay.     But  although  the  patient  may  be  little  concern- 
ed at  this  period,  yet  the  surgeon  must  not  observe  the  same 
indolence.     Aware  of  the  dangerous  consequences  of  allow- 
ing the  tumour  to  follow  its  natural  course,  he  will  apply 
leeches  once  and  again,  and  insert  an  issue  as  near  the  part 
as   possible.     The  remedies    called   discutient   have   been 
much  recommended  at  this  stage  ;  such  as  sal  ammoniac  dis- 
solved in  vinegar  ;  and  this  is  sometimes  useful,  but  perhaps 
not  more  so  than  the  vegetable  acid  by  itself:  When  it  does 
not  interfere  with  bleeding,  it  may  be  usefully  employed. 
By  means  of  these  remedies,  we  may  frequently  remove  re- 
cent tumours,  which  depend  merely  upon  the  enlargement 
of  an  organ,  without  any  other  considerable  change  of  struc> 
ture.     But  it  is  more  difficult  to  remove  tumours  which  are 
not  produced  by  the  mere  enlargement  of  a  part,  but  de- 
pend upon  a  change  of  structure,  or  the  formation  of  new 
parts ;  as,  for  instance,  warts,  polypi,  &c.     The  small  in- 
dolent tumours,  however,  which  take  place  in  the  cellular 
substance,  may  sometimes  be  removed  by  the  early  use  of 
these  remedies. 

When  these  means  have  either  been  neglected,  or  fail 
when  employed,  and  the  schirrus  begins  to  inflame,  there  is 
little  hope  of  performing  a  cure  by  either  local  ox  general 
applications  ;  and  extirpation  affords  the  only  chance  of  re- 


202 

covery  which  can  be  depended  on.  But,  as  it  is  not  always 
at  the  very  first  certain  that  the  schirrus  has  assumed  the 
cancerous  inflammation,  and  is  not  curable,  the  operation 
ought  not  to  be  advised  in  the  first  instance,  or  upon  the 
very  first  appearance  of  the  pain,  or  symptoms  of  com- 
mencing inflammation  ;  on  the  contrary,  we  ought  to  have 
recourse  to  local  bleeding,  the  use  of  issues,  mild  diet,  and 
perhaps  the  use  of  cicuta;  but  if  these  remedies  do  not 
evidently  arrest  the  progress  of  the  disease,  diminish  the 
pain  very  considerably,  and  make  the  tumour  perceptibly 
softer  and  less,  in  the  course  of  a  few  weeks,  we  ought, 
without  hesitation,  to  advise  the  removal  of  the  part,  which 
I  shall  presently  consider. 

The  local  bleeding  is  to  be  performed  with  leeches,  which 
are  preferable  to  the  scarificator,  being  attended  with  less  ir- 
ritation. Three  leeches  may  be  applied  to  the  part  every 
second  day,  as  has  been  proposed  by  some  writers  on  this 
disease.  This  practice  must  be  continued  for  a  considera- 
ble time ;  and,  during  the  intervals  of  bleeding,  cloths  dipped 
in  cold  water  ought  to  be  applied.  If,  in  the  course  of  a 
month,  the  tumour  becomes  freer  from  pain,  and  softer,  we 
may  apply  the  leeches  only  every  third  day,  and  continue 
this  for  another  month,  and  afterwards  either  persist  for 
some  time  longer  in  the  same  way,  or  repeat  the  application 
at  longer  intervals,  according  to  circumstances.  But  if,  on 
the  contrary,  the  tumour  become  rather  larger,  and  more 
painful,  as  sometimes  happens,  when  the  disease  is  farther 
advanced  before  we  begin,  and  if  the  constitution  suffer  by 
the  repeated  evacuations,  we  must  desist. 

Issues  may  be  formed,  either  by  introducing  a  small  seton 
superficially  on  ea£h  side  of  the  tumour,  or  by  blistering  the 
part,  and  afterwards  keeping  it  open  with  savine  ointment. 
The  latter  of  these  methods  is  not  admissible,  when  the  dis- 
ease has  proceeded  so  far  as  to  make^the  skin  adhere  to  the 


203 

gland  and  become  puckered  ;  indeed,  at  this  period,  issues 
formed  in  any  way  ought  never  to  be  advised,  unless  the  ope- 
ration will  not  be  consented  to  ;  because  the  chance  of  their 
producing  a  cure  is  very  little,  and  we  lose  time  by  trusting 
to  them. 

Mild  and  spare  diet  has  a  very  considerable  influence 
over  this  disease,  in  almost  every  period,  and  contributes 
greatly  to  retard  its  progress.  It  ought  therefore  rigidly  to 
be  conjoined  with  the  bleeding  and  issues,  in  the  commence- 
ment of  the  disease,  and  will  tend  to  abate  the  action  in  the 
part,  and  promote  its  resolution.  The  diet  ought  to  consist 
of  stewed  apples,  or  prunes,  panada,  and  weak  broths,  with 
bread.  It  has  even  been  proposed  to  prohibit  almost-  en- 
tirely the  use  of  solid  food,  and  to  allow  the  patient  nothing 
but  water  for  the  course  of  several  weeks.  This  was  much 
recommended  by  M.  Pouteau,  who  was  led  to  make  trial  of 
it  by  the  success  attending  the  empirical  practice  of  an  ec- 
clesiastic. It  was  afterwards  enforced  by  Callison ;  and 
more  lately  abstinence  has  been  favourably  mentioned  by  Mr. 
Pearson,  who  relates  some  cases  of  cancer,  or  appearance  of 
cancer,  in  the  uterus,  in  which  it  produced  very  astonishing 
effects,  abating  the  pain,  diminishing  the  swelling,  and  re-es- 
tablishing the  general  health. 

By  means  of  these  remedies,  we  may  sometimes  succeed 
in  removing  by  degrees  a  schirrus,  after  it  has  evidently  be- 
gun to  inflame,  and  threatens  to  become  cancerous.  But  if, 
notwithstanding  these  remedies,  the  disease  evidently  con- 
tinues to  increase,  or  if,  in  the  course  of  a  few  weeks,  they 
do  not  produce  an  evident  effect,  we  cannot  with  propriety 
delay  the  operation,  which  is  the  most  certain  method  of 
cure,  and  one  which  succeeds  in  a  majority  of  instances,  if 
early  and  properly  performed  ;  nor  ought  any  other  method 
of  treatment  to  be  proposed  in  opposition  to  it,  unless  in  the 
very  commencement  of  the  inflammatory  state  ;  aud  it  is  in 

VOL.  II.  2   c 


204 

this  period  only  that  I  propose  the  above  treatment,  unle3» 
the  patient  absolutely  decline  the  operation  ;  for  when  the 
skin  becomes  puckered,  and  the  inflammation  has  continued 
clearly  for  a  considerable  time,  without  any  measures  being 
taken  to  remove  it,  the  success  of  any  local  or  general  re- 
medy is  exceedingly  precarious,  and  delay  is  not  only  useless, 
but  frequently  dangerous.  It  has,  however,  been  doubted 
by  some  very  ingenious  surgeons,  whether  it  was  proper  to 
advise  the  operation  at  any  period,  they  believing,  from  the 
number  of  relapses,  that  it  was  almost  useless  ;  whilst  other* 
have  been  against  the  early  performance  of  it,  on  the  prin- 
ciple, that  some  parls  already  diseased  might  not  have,  at 
this  period,  become  evidently  affected ;  and,  therefore, 
might  inadvertently  be  allowed  to  remain. 

The  late  Dr.  Monro,*"  from  observing,  that  almost  all  the 
patients  on  whom,  to  his  knowledge,  the  operation  had  been 
performed,  relapsed,  is  inclined  rather  to  adopt  the  palliative 
treatment,  than  the  extirpation.  He  takes  for  granted,  that, 
in  the  generality  of  cases,  cancer  depends  upon  some  internal 
cause.  In  these  cases,  he  is  decidedly  averse  from  the  ope- 
ration, and  advises  it  only  when  the  disease  occurs  owing  to 
blows  or  hurts  in  young  and  healthy  people.  But,  in  consi- 
dering this  opinion,  we  are  to  remember,  that  a  great  many 
of  these  cases  may  be  supposed  to  have  been  very  far  ad- 
vanced before  any  operation  was  performed ;  and  likewise, 
that  the  method  of  operating,  in  that  period,  was  extremely 
unfavourable  to  a  cure,  the  wound  being  kept  open,  and  sup- 
purations and  ulceration  rather  encouraged  than  avoided. 
More  lately,  Mr.  Hill  of  Dumfries  has  published  an  account 
of  cases,  where  the  operation  was  performed  in  more  favoura- 
ble circumstances,  and  of  these  not  a  seventh  part  suffered  a. 
relapse.  The  present  Dr.  Monro  gives  even  a  more  favourable: 

*  Med.  Essays,  Vol.  V.  p.  422. 


205 

account ;  for,  if  I  am  not  much  mistaken,  he  observes,  in  his 
lectures,  that  not  one-third  of  the  cases  in  which  he  had 
been  consulted,  had  relapsed.  From  my  own  observations, 
I  cannot  judge  very  accurately ;  because  many  of  those  on 
whom  I  have  operated,  came  from  parts  at  a  great  distance, 
and  with  which  I  had  no  intercourse ;  consequently,  I  could 
not  hear  of  the  result  of  those  cases :  But  of  the  cases,  the 
sequel  of  which  I  have  heard,  not  a  fifth  part  have  relapsed ; 
and  in  those  the  operation  was  performed  at  a  period  whep 
the  axillary  glands  had  become  diseased,  but  were  not  evi- 
dently so ;  and,  therefore,  were  not  extirpated  ;  for,  in  all  of 
them.,  the  disease  reappeared  in  the  lymphatic  glands.  But, 
even  from  this  relapse,  the  patients  may  be  cured  by  a  se- 
cond operation.  We  may,  therefore,  conclude,  that,  if  the 
operation  be  early  performed,  the  majority  will  recover ;  and 
even  although  the  disease  should  afterwards  appear  in  the 
lymphatic  glands*  the  patient  is  not  incurable ;  for  we  fre- 
quently succeed  in  extirpating  cancers,  when  the  glands  are 
very  much  affected  before  we  are  applied  to.  I  have  ope- 
rated in  cases  where  I  was  obliged  to  dissect  the  glands, 
from  the  axillary  artery  along  almost  all  its  course  in  the 
arm-pit,  and  which  reached  well  nigh  to  the  articulation. 

With  regard  to  the  argument  against  the  early  extirpa- 
tion, founded  upon  the  possibility  of  the  disease  having  af 
fected  parts  in  the  vicinity,  which  have  not  yet  evidently 
become  diseased,*  I  may  observe,  that,  upon  the  same  prin- 
ciple, Ave  ought  not  to  operate  until  the  axillary  glands 
swell;  because  they  may  be  affected,  although  they  be  not 
yet  evidently  enlarged ;  and,  therefore,  may  give  rise  to  a 
relapse.  If  we  only  remove  the  single  gland  in  the  breast, 
which  is  hard,  we  doubtless  run  a  great  hazard  of  a  relapse ; 
but,  I  apprehend,  that  this  ought  never  to  be  done,  and  that 

"*  -Tract.  Obs.  on  Cancerous  Complaints,  by  Mr.  Pearson,  p.  50, 


•206 

the  whole  of  the  glandular  part  of  the  breast  ought  to  be  re 
moved  at  once ;  because  we  thus  more  certainly  prevent  a 
return  of  the  disease,  which  we  cannot  otherwise,  with  any 
certainty,  do.  The  additional  pain  is  very  inconsiderable ; 
and  we  can  derive  very  little  advantage  or  benefit  from  leav- 
ing a  part  of  the  mamma  behind. 

The  caustic  has  been  proposed,  instead  of  the  knife,  for 
the  removal  of  cancer  or  schirrus ;  but  it  is  much  less  cer- 
tain, more  tedious,  and  even  more  painful.  Instead,  there- 
fore, of  recommending  itself  to  timorous  patients,  this  prac- 
tice is  still  more  to  be  dreaded,  than  the  excision,  which  is 
more  terrible  in  anticipation,  than  in  the  actual  performance 
of  it. 

The  caustic  most  commonly,  and  indeed  almost  universal- 
ly, employed,  is  arsenic  mixed  with  various  inert  substances, 
and  formed  into  a  paste  or  ointment.*  This  has  been  ap- 
plied in  two  ways ;  first,  directly  upon  the  skin,  covering 
the  schirrus,  and  then,  after  this  is  destroyed,  upon  the 
schirrus  itself,  destroying  it  layer  by  layer  ;  second,  direct- 
ly upon  the  skin,  and  then,  instead  of  applying  it  to  the 
gland,  to  put  it  round  it  on  the  surrounding  cellular  sub- 
stance, and  by  gradually  destroying  this  round  the  gland,  to 
turn  out  the  schirrus  entire.  This  was  the  practice  of  Mr. 
Guy,  who  gained  considerable  credit  by  his  success ;  and, 
since  his  time,  it  has  occasionally  been  performed  with  suc- 
cess by  some  others. f 


*  Arsenic  mixed  with  sulphur,  and  powdered  crow-foot,  and  made  into  a  paste 
with  yolk  of  egg,  forms  Plunket's  composition.  Mixed  with  forty  times  its  weight 
of  powder  of  belladona,  it  forms  an  application  which  gome  time  ago  was  much  ia 
repute  in  North  America. 

f  Justamond  on  Cancers,  p.  111.  This  gentleman  relates  a  case,  in  which,  by 
destroying  the  skin  with  lunar  caustic,  and  then  applying  arsenic,  he  removed  the 
gland.  The  arsenic,  in  this  instance,  was  fused  with  antimony,  in  proportion  of 
two  parts  of  the  first  to  one  of  the  last.  This  was  powdered  and  mixed  with  equal 
parts  of  powdered  opium,  and  made  into  a  liniment  with  yolk  of  egg. 


207 

This  method,  however,  is  liable  to  several  material  objec- 
tions :  It  is  uncertain  in  its  issue  ;  for,  if  the  gland  be  not 
completely  removed,  the  disease  makes  a  rapid  progress  af- 
terwards. It  frequently  happens,  that  some  smaller  gland* 
around  the  large  one  are  affected ;  and  these  are  greatly  irri- 
tated by  the  action  of  the  caustic  in  their  vicinity :  It  is 
more  painful  than  the  operation  with  the  knife;  and  the  sub- 
sequent process  of  healing,  even  granting  the  method  to  suc- 
ceed in  removing  the  diseased  part,  is  much  more  tediou* 
than  when  the  incision  is  employed,  and  union  by  the  firsi 
intention  procured. 

On  all  these  accounts,  but  most  especially  on  account  of 
its  uncertainty,  the  method  of  cure  by  caustic  can  never  be 
sanctioned  by  any  modern  surgeon,  much  less  can  it  ever  be 
held  up  in  opposition  to  extirpation  by  the  knife. 

This  practice,  which  has  had  many  advocates  for  its  em- 
ployment in  schirrus,  has  been  equally  recommended  in  cases 
of  cancerous  ulcers  ;  but  here  it  is  still  less  admissible  ;  for 
the  extent  of  diseased  parts  is  generally  greater  ;  the  neigh- 
bouring parts  are  affected  lo  a  greater  distance  ;  indurated 
and  diseased  lymphatics  frequently  extend  from  the  breast 
to  glands  in  the  axilla.  It  is,  therefore,  next  to  impossible 
to  turn  out  the  morbid  parts,  as  "  nuclei,"  by  destroying 
the  substance  around  them  ;  and  it  is  equally  improbable 
that  we  shall,  unless  the  sore  be  very  small,  and  the  caustic 
very  strong,  be  able  to  make  it  slough  off  in  successive  layers. 
Farther,  we  can  propose  no  advantage  to  ourselves,  from  em- 
ploying caustic  in  preference  to  the  scalpel  ;  because  in 
every  instance  in  which  we  can  destroy  the  parts  by  means 
of  this,  we  can  equally  safely,  infinitely  more  speedily,  and 
with  much  less  pain,  remove  the  parts  with  the  knife.  There 
is  only  one  case  in  which  caustic  is  useful,  and  that  is 
merely  as  an  appendage  to  the  operation  of  excision  When 
we  dissect  off  ulcers  from  parts  where,  owing  to  the  want  of 


208 

cellular  substance,  the  skin  is  not  lax  enough  to  be  brought 
over  the  parts,  or  when  so  much  of  this  has  been  removed, 
that,  although  lax,  it  cannot  be  made  to  cover  it,  we  may 
find  it  of  service  to  rub  the  bottom  of  the  wound  with  lunar 
caustic,  as  we  thus  stop  the  oozing  of  blood,  and  destroy  any 
little  portions  of  the  diseased  part  which  we  may  have  left. 
For  the  purpose  of  destroying  cancerous  ulcers,  many 
caustics  and  escharotics  have  been  proposed,  such  as  the 
arsenic,  corrosive  sublimate,  lunar  caustic,  Sec.  Of  these 
no  one  seems  to  possess  a  preference  over  the  rest,  if  we 
consider  only  their  local  action  ;  but  some  of  them,  espe- 
cially arsenic,  are  apt  to  produce  bad  effects,  and  that  very 
nnexpectedly,  on  the  constitution. 

After  making  these  remarks  upon  the  method  of  cure,  I 
shall  conclude  with  some  observations  on  different  reme- 
dies, which  have  been  proposed  as  palliatives,  where  the 
operation  is  not  admissible,  or  will  not  be  consented  to,  and 
which  have  even  been  supposed  capable  of  changing  the 
mode  of  acting  altogether,  and  producing  of  themselves  a 
cure.  These  remedies  I  shall  divide  into  general  and  to- 
pical. 

Of  the  general  remedies,  those  which  have  been  most  fre- 
quently, and  with  the  greatest  confidence,  employed,  are 
narcotics,  such  as  the  cicuta,  opium,  night-shade,  &c. 

The  cicuta  is  a  medicine  which  was,  at  one  time,  in  very 
high  repute,  and  owed  its  reputation  to  the  experimenting 
talent  of  Storck,  who  has  written  several  libelli  on  this 
plant.  According  to  him,  cicuta  possesses  very  evident 
powers  over  cancer,  and  has  cured  a  great  many  cases  ;  but, 
in  less  prejudiced  hands,  it  has  been  much  less  successful ; 
and  even  in  many  of  the  instances  adduced  by  Baron  Storck 
of  its  utility,  it  is  by  no  means  proved,  that  the  disease  was 
really  cancer.  The  present  opinion  of  the  public  seems  to 
he  very  unfavourable  with  regard  to  this  medicine  ;  and  from 


209 

the  numerous  instances  in  which  it  has  failed,  this  opinioa 
•eeras  to  be  very  just.  Along  with  the  proper  local  appli- 
cations which  have  been  formerly  noticed,  it  sometimes  is  of 
service  in  removing  simple  schirri  ;*  but  I  have  never  found 
it  of  any  service  when  the  schirrus  had  assumed  the  cancer- 
ous inflammation,  much  less  when  it  has  proceeded  the  length 
of  ulceration.  In  the  last  case,  I  have  never  found  it  even 
produce  the  temporary  melioration  which  many  talk  of. 

The  common  way  of  exhibiting  the  hemlock,  is  to  begin 
with  small  doses,  and  increase  these  gradually,  until  they 
produce  vertigo  :  For  this  purpose,  we  may  begin  with  two 
grains  of  the  extract,  or  four  of  the  powder,  recently  prepared, 
twice  or  thrice  a-day,  and  gradually  increase  the  quantity .f 
In  this  way,  we  find  that  some  patients  have  come  to  take  an 
ounce  of  the  extract  daily  ;  but  if  a  much  less  quantity  than 
this  produce  no  good  effect,  we  may  consider  it  as  useless  to 
continue  a  remedy,  which,  in  this  dose,  must  injure  the  con- 
stitution every  day  that  it  is  continued.  On  the  continent, 
the  hemlock  has  been  used  in  the  form  of  a  bath  ;  but  it  is  so 
disagreeable,  that  few  can  be  brought  to  use  if. 

The  belladona  has  been  much  recommended  by  Lamber- 
%en,  who  tried  it  in  many  cases  of  cancer;  but  these  trials, 
when  repeated  with  attention, have  not  been  greatly  in  favour 
of  the  remedy.  During  its  use,  he  kept  the  bowels  open 
with  clysters,  administered  every  second  day.  The  dose, 
at  first,  ought  to  be  a  grain  of  the  dried  leaves,  made  into  a 


"  If  I  am  not  mistaken,  the  present  Dr.  Monro  mentions,  ia  hi»  lectures,  one 
Instance,  in  which  a  small  schirrus  appeared  to  be  removed  by  it;  but  whether 
this  was  simple  or  cancerous,  I  do  not  know. 

t  As  different  parcels  of  this  medicine  may  not  be  of  the  same  strength,  it  is 
prudent,  when  we  begin  a  new  supply,  that  we  diminish  the  dose  at  first,  if  it 
have  formerly  been  very  considerable.  Br  net  attending  to  tbh,  fatal  effects  have 
Allowed. 


210 

pill.     This,  in  the  beginning,  is  to  be  given  morning  and 
evening,  and  afterwards  more  frequently. 

The  hyocyamus  has  also  been  frequently  used  in  cancer, 
and  was  very  much  in  repute  with  the  ancients.  - 1  have 
tried  it  occasionally,  but  with  very  little  effect.  The  dose 
with  which  we  begin,  is  two  grains  of  the  extract. 

The  aconitum  is  a  more  powerful  and  dangerous  narcotic, 
in  so  much  that  a  quarter  of  a  grain  of  the  extract  is  gene- 
rally the  dose  with  which  we  begin. 

The  solanum  dulcamara,  Paris  quadrifolia,  phytolacca,  &c. 
have  been  likewise  recommended  and  employed,  but  are 
now  so  little  used,  that  it  is  unnecessary  to  take  any  notice 
of  them  here.* 

The  laurus  cerasus  is  a  very  powerful  narcotic,  and  has 
been  used,  in  this  particular  complaint,  by  Richter,  but 
with  very  little  success.  The  most  common  preparation  of 
this  medicine,  is  the  distilled  water ;  but  the  dose  of  this  is 
very  uncertain.  Some  have,  therefore,  proposed  to  give, 
for  a  dose,  four  or  five  grains  of  the  fresh  leaves  infused  in  a 
little  water. 

The  digitalis  has  a  considerable  power  of  abating  vascular 
action,  and  may,  therefore,  be  of  use,  in  the  same  point  of 
view  with  abstinence,  bleeding,  &c.  in  abating  the  action  of 
schirri ;  but  concerning  its  real  utility  in  this  disease,  I  can- 
not say  any  thing  with  certainty. 

Opium  is  seldom  employed  with  an  intention  of  curing 
this  disease,  although  it  is  probable,  that  it  possesses  just  as 
much  power  over  cancer,  as  those  other  narcotics  which 
have  been  more  frequently  used.  It  is,  however,  liberally 
employed  with  a  view  to  abating  the  pain  of  cancerous  ul- 
eers. 

*  I  have  tried  the  hepatized  ammonia,  but  without  any  benefit. 


311 

Tonic  remedies  have  frequently  been  used  in  this  disease  ; 
but  although  they  may  sometimes  improve  the  general 
health,  yet  they  never  produce  any  effect  upon  the  local 
disease.  On  this  account,  they  are  now  very  seldom  em- 
ployed. 

Arsenic  is  a  medicine,  which  has,  by  some,  been  consi- 
dered as  a  specific  against  cancer  ;*  but  even  those  who 
maintain  this,  add,  that  although  they,beliere  and  think  so, 
yet  they  have  not  been  able  to  administer  it  in  such  quanti- 
ties as  to  produce  any  good  effect. 

Mercuryf  has  also  been  recommended  ;  but  there  is  no 
fact  more  certainly  ascertained  than  this,  that  mercury  uni- 
formly exasperates  this  disease,  especially  when  it  has  pro- 
ceeded the  length  of  ulceration.  In  this  case,  the  sores  en- 
large rapidly,  become  much  more  painful,  and  bleed  frequent- 
ly.  It  is  worthy  of  observation,  that  those  who  are  affect- 
ed with  cancer,  have  in  general  the  mercurial  action  induced 
very  easily  and  very  speedily  ;£  and  the  changes  which 
take  place  on  the  ulcer  are  equally  rapid.  This  circumstance, 
of  mercury  increasing  the  disease,  in  so  marked  a  manner  as 
it  usually  does,  ought  not  only  to  make  surgeons  careful  of 
exhibiting  this  remedy,  upon  slight  suspicions  of  the  sore 
being  venereal,||  but  may  likewise  be  attended  to  as  a  step 
toward  the  discovery  of  a  better  mode  of  treatment  for  can- 
cer than  we  yet  possess  ;  because  if,  at  any  time,  we  dis- 
cover the  means  of  directly  displacing  and  counteracting  the 
mercurial  action,  we  may  perhaps  find  the  same  to  be  useful 
in  abating  the  cancerous ;  these  two  actions  appearing  to  pos- 
sess some  general  coincidence,  from  their  mutual  effect  in 
increasing  each  other. 

*  Justamcrad  on  Cancers. 

f  Along  with  this,  it  was  customary  to  prescribe  decoctions  of  gnaiac  sarsapa. 
▼ilia,  &c. 

\  It  likewise  continues  very  long  after  giving  up  the  use  of  the  mercury. 
||  Some  cases  of  this  kind  I  have  already  mentioned. 
VOL.    ft.  D   2 


212 

Copper,  in  the  form  of  cuprum  vitriolatum,  has  been  used 
in  cancer ;  and  one  case  is  recorded,  in  which  it  is  said  to 
have  produced  a  cure  ;  but  in  every  other  case  it  has  failed  ; 
and,  from  the  violent  effects  which  it  is  apt  to  produce,  con- 
siderable danger  attends  its  exhibition. 

Muriated  barytes  has  been  proposed  as  a  cure  for  this  dis- 
ease; but  now  none  employ  it  with  this  expectation. 

The  same  remedies  which  internally  have  been  supposed 
to  cure  cancer,  have  also  been  proposed  as  local  applica- 
tions. 

Among  the  older  practioners,  narcotics  were  very  cur- 
rently employed  as  a  dressing  for  cancerous  sores.  Vesali- 
us  used  cloths  dipped  in  the  juice  of  the  solanum;  whilst 
others  employed  it  mixed  with  oil  of  roses,  and  preparations 
of  lead  and  antimony.  Others  had  recourse  to  the  hyocy- 
amns  ;  whilst  of  late  the  cicuta  poultices  seem  to  have  super- 
seded the  use  of  most  other  narcotic  preparations.  These 
have,  undoubtedly,  in  many  cases,  abated  the  pain,  and  di- 
minished the  foetor ;  but  this  is  all  which  can  reasonably  be 
expected  from  them ;  and  even  this  expectation  will  not  al- 
ways be  realized. 

Carrot  poultices  are  still  more  useful,  as  they  possess  the 
property  of  abating  the  foetor,  in  a  degree  superior  to  the 
hemlock,  and  give  generally  as  much  ease.  This  foetor 
has  been  long  compared  to  the  smell  of  hepar  sulphuris,  and 
lately  has  been  supposed  to  arise  altogether  from  the  forma- 
tion of  a  substance  of  this  nature,  consisting  of  sulphur  and 
volatile  alkali.  As  it  has  been  too  much  the  case  in  medi- 
cine, to  overlook  causes,  and  attend  to  effects,  so  we  are  not 
to  be  surprised  if  we  find  some  physicians  proposing  to  cure 
cancer,  by  remedies  which  shall  decompose  the  matter  which 
is  yielded  in  that  disease,  or  destroy  the  effect  of  the  mor- 
bid action,  whilst  the  action  itself  is  overlooked.*     From 

*  Although  the  foetor  may  depend  upon  the  presence  of  hepatized  ammonia,  yet 


213 

experiments  made  upon  the  hepatized  ammonia,  it  was  found, 
that  the  oxygenated  muriatic  acid  was  the  best  agent  for  de- 
composing it,  and  destroying  its  smell.  This  fluid  was, 
therefore,  highly  recommended  as  an  application  for  cance- 
rous sores ;  and,  in  many  instances,  it  will  indeed  be  found 
to  correct  the  foetor,  which  is  certainly  one  advantage  ;  but 
it  never  will  perform  a  cure. 

Carbonic  acid  has  been  said  not  only  to  correct  the  foetor, 
but  also,  in  some  instances,  completely  to  cure  the  disease. 
It  was  long  ago  proposed  by  M.  Peyrilhe,  and  of  late  it  has 
again  been  brought  forward  by  Dr.  Ewart,  who  has  publish- 
ed a  case  in  which  it  produced  cicatrization ;  but  although, 
upon  his  recommendation,  it  has  been  frequently  employed, 
yet  it  has  very  seldom  been  of  any  considerable  service,  and 
I  have  heard  of  no  instance  in  which  it  produced  any  per- 
manent amendment.  It  would  rather  appear,  that  the 
©pinion  of  M.  de  Fourcroy  was  the  just  one :  "  After  the 
first  applications,  (says  he,)  the  cancerous  sore  appears  to 
assume  a  more  favourable  aspect,  the  sanies  which  flowed 
from  it  becomes  whiter,  thicker,  and  purer,  and  the  flesh  has 
a  redder  and  fresher  colour ;  but  these  flattering  appearances 
are  deceitful,  nor  do  they  continue  long,  for  the  sore  speedi- 
ly returns  to  its  former  state,  and  its  progress  goes  on  as  be- 
fore the  application."  The  best  method  of  applying  this, 
is  by  means  of  a  bladder,  the  mouth  of  which  is  fastened 
round  the  sore,  by  means  of  adhesive  plaster.  The  air  is 
introduced  by  a  pipe  inserted  at  the  other  end.  When  first 
applied,  the  gas  produces  a  sensation  of  coldness,  which  is 
soon  followed  by  a  glowing  heat,  and  abatement  of  the  pe- 
culiar pain  of  the  sore.  At  other  times,  it,  from  the  first, 
produces  a  smarting,  and  makes  the  patient  rather  more  un- 


this  does  no  harm  to  the  ulcer.  On  the  contrary,  I  have  sometimes  found  the  ap- 
plication of  this  fluid,  when  mixed  with  water,  hare  the  effect  if  abating  the 
ptfin.- 


214 

easy.  This  is  especially  the  case  if  we  use  the  fermenting 
poultice,  instead  of  the  air  already  extricated. 

Digitalis,  applied  either  in  poultices  or  infusion,  has  been 
said  to  abate  the  pain,  and  meljorate  the  appearance  of  the 
sore ;'  but,  in  this  respect,  it  seems  to  be  very  much  on  a  le- 
vel with  cicuta. 

Tar  ointment,  gastric  juice,  absorbent  powders,  and  many 
other  applications,  which  it  is  unnecessary  to  enumerate, 
have  been  proposed;  but  as  their  utility  is  by  no  means 
evinced,  I  shall  not  detain  the  reader  with  any  remarks  upon 
them. 

Caustic,  and  escharotic  preparations,  have  been  already 
considered. 

Upon  the  whole,  when  the  ulcer  does  not  admit  of  being 
extirpated,  all  which  can  be  done,  is  to  keep  the  sore  clean, 
by  washing  it  carefully,  and  dressing  it  with  some  mild  oint- 
ment, or  using  some  of  the  poultices  or  lotions  already  men- 
tioned, if  these  do  not  gall  the  skin,  at  the  same  time  that 
we  keep  the  patient  easy  by  administering  x>pium. 


Having  now  concluded  these  observations  on  the  cancer- 
ous inflammation,  I  should  next  proceed  to  the  consideration 
of  the  venereal  inflammation ;  but  the  dissertations  on  this 
subject  must  be  reserved  for  another  volume. 


EXD    OF    VOL.  II. 


Date  Due 

L.  B.  Cat.  No.  1 13  7 

613.57     B967     7a 


Burns 


43540 


